ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is teaching a client who is lactose intolerant about dietary choices. Which food should the nurse recommend to increase calcium intake?
- A. Spinach
- B. Peanut butter
- C. Ground beef
- D. Carrots
Correct answer: A
Rationale: The correct answer is A: Spinach. Spinach is rich in calcium, making it a suitable choice for individuals with lactose intolerance who need to avoid dairy products. Peanut butter, ground beef, and carrots are not significant sources of calcium compared to spinach, and therefore, not the best recommendation for increasing calcium intake in lactose-intolerant individuals.
2. A nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury (TBI). What finding should the nurse recognize as a complication and report to the provider?
- A. Hypertension
- B. Vomiting
- C. Drainage from the ear
- D. Unequal pupils
Correct answer: D
Rationale: Unequal pupils are a sign of increased intracranial pressure or worsening brain injury, indicating a serious complication that requires immediate medical attention. Hypertension, vomiting, and drainage from the ear are not typically associated with minor traumatic brain injury complications; therefore, they are not the priority findings to report to the provider.
3. A client who has a new prescription for simvastatin is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will take this medication in the morning.
- B. I should avoid drinking grapefruit juice while taking this medication.
- C. I should expect my cholesterol levels to increase initially.
- D. I will need to have my kidney function checked every 3 months.
Correct answer: B
Rationale: The correct answer is B. Grapefruit juice can increase the risk of toxicity with simvastatin, so clients should avoid consuming it while on the medication. Choice A is incorrect because the timing of medication administration should be based on healthcare provider instructions. Choice C is incorrect because simvastatin is prescribed to lower cholesterol levels. Choice D is incorrect as monitoring kidney function is not specifically related to simvastatin therapy.
4. A client with a permanent spinal cord injury is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?
- A. “I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league.”
- B. “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.”
- C. “I’m so upset that this happened to me. What did I do to deserve this, and why am I not getting better?”
- D. “I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my family.”
Correct answer: A
Rationale: Choice A is the correct answer. This statement demonstrates effective coping as the client is showing acceptance of their disability and planning for the future with realistic goals. Choice B reflects denial of the permanent disability by stating that they will only be in a wheelchair temporarily. Choice C shows distress and a lack of acceptance by questioning why the injury happened and why they are not improving. Choice D indicates feelings of hopelessness and being a burden, which are not signs of effective coping.
5. A client is receiving morphine. Which of the following should the nurse monitor?
- A. Liver function
- B. Respiratory rate
- C. Blood glucose levels
- D. Bowel sounds
Correct answer: B
Rationale: Corrected Rationale: When a client is receiving morphine, monitoring the respiratory rate is crucial because morphine can cause respiratory depression. Therefore, it is essential for the nurse to assess the client's breathing to detect any signs of respiratory distress. Choices A, C, and D are incorrect because morphine primarily affects the respiratory system, not the liver function, blood glucose levels, or bowel sounds.
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