a nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

1. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

Correct answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

2. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

3. A nurse is teaching a client who is lactose intolerant about dietary choices. Which food should the nurse recommend to increase calcium intake?

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.

4. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?

Correct answer: C

Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.

5. A nurse is caring for a client who has end-stage osteoporosis and is reporting severe pain. The client’s respiratory rate is 14 per minute. Which of the following medications should the nurse prioritize administering?

Correct answer: B

Rationale: Hydromorphone, an opioid, is the most appropriate option for managing severe pain in this context. Opioids provide fast-acting relief for acute pain associated with advanced osteoporosis. Promethazine (Choice A) is an antihistamine and not indicated for pain relief. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may increase the risk of bleeding and is not recommended for severe pain management. Amitriptyline (Choice D) is a tricyclic antidepressant that is not the first-line treatment for severe acute pain.

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