ATI RN
ATI Capstone Comprehensive Assessment B
1. The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?
- A. Loss of weight
- B. Loss of bone mass
- C. Loss of hope
- D. Loss of strength
Correct answer: C
Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.
2. How should a healthcare professional administer a subcutaneous injection?
- A. Insert the needle at a 45-degree angle
- B. Insert the needle at a 90-degree angle
- C. Use a Z-track method
- D. Insert the needle at a 15-degree angle
Correct answer: A
Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.
3. Nurse Rose is caring for a client with cancer who has developed spinal cord compression. Which of the following symptoms would the nurse expect to find?
- A. Decreased deep tendon reflexes
- B. Severe headache
- C. Back pain
- D. Loss of bladder control
Correct answer: C
Rationale: The correct answer is C: 'Back pain.' Back pain is a common symptom of spinal cord compression in cancer patients. This condition can cause localized or radiating back pain due to the compression of the spinal cord or nerves. While symptoms such as decreased deep tendon reflexes, severe headache, and loss of bladder control can occur in other conditions, back pain is specifically associated with spinal cord compression in cancer patients.
4. What action is essential for a community health nurse to assess environmental health risks?
- A. Collecting data on community health behaviors
- B. Conducting health screenings
- C. Assessing workplaces for potential hazards
- D. Monitoring air and water quality
Correct answer: D
Rationale: Community health nurses play a vital role in assessing environmental health risks by monitoring air and water quality. This action helps identify potential hazards that may impact the health of individuals in the community. By monitoring these environmental factors, nurses can gather important data to address and mitigate health risks associated with poor air or water quality.
5. A client has a new prescription for a Fentanyl transdermal patch. Which of the following instructions should the nurse include?
- A. Apply the patch to a non-hairy area.
- B. Change the patch every 72 hours.
- C. Avoid exposure to heat sources.
- D. Do not cut the patch to adjust the dosage.
Correct answer: C
Rationale: The correct instruction the nurse should include for a client using a Fentanyl transdermal patch is to avoid exposure to heat sources. Heat can increase the absorption of the medication, potentially causing an overdose. Instructing the client to avoid heat sources is crucial to ensure their safety and the effectiveness of the medication. Choices A, B, and D are incorrect because applying the patch to a non-hairy area, changing it every 72 hours, and not cutting the patch are general guidelines for using transdermal patches but do not specifically address the unique risks associated with Fentanyl patches.
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