ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following is an appropriate description of the use of hypnosis during labor?
- A. Hypnosis focuses on biofeedback as a relaxation technique
- B. Hypnosis promotes increased control of pain perception during contractions
- C. Hypnosis uses therapeutic touch to reduce anxiety during labor
- D. Hypnosis provides instruction to minimize pain
Correct answer: B
Rationale: The correct answer is B. Hypnosis during labor helps the client gain increased control over her perception of pain, allowing for better pain management during contractions. Choice A is incorrect because hypnosis and biofeedback are distinct techniques. Choice C is incorrect as therapeutic touch and hypnosis are different modalities. Choice D is incorrect as hypnosis does not simply provide instruction to minimize pain, but rather helps the individual control their perception of pain.
2. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn’s actions as uncooperative
Correct answer: D
Rationale: The correct answer is D because viewing the newborn’s actions as uncooperative indicates a negative interaction with the newborn and suggests impaired bonding, which requires intervention. Choices A, B, and C are not indicative of impaired bonding. Holding the newborn in an en face position is a positive way to bond with the baby. Asking the father to change the diaper shows involvement of both parents in caring for the newborn, which is beneficial for bonding. Requesting the nurse to take the newborn to the nursery so the mother can rest is a normal request and does not necessarily indicate impaired bonding.
3. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?
- A. Decreased deep tendon reflexes
- B. Elevated blood pressure
- C. Increased urinary output
- D. Hyperreflexia
Correct answer: A
Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.
4. A nurse is teaching a group of clients about stress management. Which of the following activities should the nurse recommend to reduce stress?
- A. Watching television
- B. Deep breathing exercises
- C. Drinking coffee
- D. Avoiding exercise
Correct answer: B
Rationale: Deep breathing exercises are effective in reducing stress by promoting relaxation and lowering heart rate, making them a recommended technique. Watching television may not actively reduce stress but can serve as a distraction. Drinking coffee, which contains caffeine, may increase anxiety levels. Avoiding exercise can lead to pent-up stress and tension rather than reducing it.
5. A nurse is assessing a client with chronic kidney disease. Which of the following findings should the nurse monitor?
- A. Hypokalemia
- B. Fluid overload
- C. Decreased blood pressure
- D. Increased appetite
Correct answer: B
Rationale: The correct answer is B: Fluid overload. Clients with chronic kidney disease are prone to fluid overload due to impaired kidney function. The kidneys may not effectively regulate fluid balance, leading to fluid retention. Monitoring for signs of fluid overload, such as edema, hypertension, and shortness of breath, is crucial. Choice A, Hypokalemia, is less likely in chronic kidney disease as the kidneys often have difficulty excreting potassium, leading to hyperkalemia. Decreased blood pressure (Choice C) is not a common finding in chronic kidney disease unless complications like volume depletion occur. Increased appetite (Choice D) is not typically associated with chronic kidney disease; in fact, many clients may experience a decreased appetite due to various factors such as uremia and dietary restrictions.
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