ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What are the complications of diabetes mellitus that a nurse should monitor for?
- A. Peripheral neuropathy and retinopathy
- B. All of the above
- C. Diabetic ketoacidosis and hyperosmolar hyperglycemic state
- D. Nephropathy and cardiovascular disease
Correct answer: D
Rationale: The correct answer is D. Complications of diabetes mellitus that a nurse should monitor for include nephropathy and cardiovascular disease, in addition to diabetic ketoacidosis, hyperosmolar hyperglycemic state, neuropathy, and retinopathy. While choices A and C mention some complications of diabetes, they do not cover all the complications that a nurse should monitor for. Choice B is incorrect as it suggests selecting all options, which is not accurate.
2. How can dehydration be assessed in an elderly patient?
- A. Checking skin turgor on the forearm
- B. Assessing for dry mucous membranes
- C. Checking for orthostatic hypotension
- D. Measuring daily weights
Correct answer: A
Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.
3. A client with a history of falls is being admitted to the unit. What intervention should the nurse implement first?
- A. Increase the client's medication to ensure they don't fall.
- B. Use bed alarms to monitor the client's movements.
- C. Encourage the client to use a walker for mobility.
- D. Assign the client to a nursing assistant for supervision.
Correct answer: B
Rationale: The correct answer is B: 'Use bed alarms to monitor the client's movements.' When a client with a history of falls is admitted, the nurse's initial intervention should focus on fall prevention measures. Using bed alarms to monitor the client's movements can help alert the healthcare team if the client attempts to get out of bed and reduce the risk of falls. Choice A is incorrect because increasing medication should not be the first intervention as it may not address the underlying causes of falls and can have adverse effects. Choice C may be appropriate but is not the priority over implementing safety measures like bed alarms. Choice D is incorrect as assigning the client to a nursing assistant for supervision alone may not be as effective as utilizing bed alarms for continuous monitoring.
4. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?
- A. Encourage physical activity to reduce withdrawal symptoms
- B. Administer diazepam to prevent seizures
- C. Monitor for signs of dehydration
- D. Encourage the client to verbalize their feelings
Correct answer: B
Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.
5. A female client with anxiety disorder is being taught about alprazolam by a nurse. Which of the following information should the nurse include in the teaching?
- A. This medication may increase your blood pressure
- B. Use a reliable form of contraception while taking this medication
- C. If a dose is missed, double the next dose of medication
- D. Do not eat aged cheeses while taking this medication
Correct answer: B
Rationale: The correct answer is B. Alprazolam can increase the risk of pregnancy complications, so using a reliable form of contraception is essential to prevent unintended pregnancies. Choice A is incorrect because alprazolam typically does not increase blood pressure. Choice C is incorrect as doubling the next dose after a missed dose can lead to overdose and adverse effects. Choice D is unrelated to alprazolam and is not a concern when taking this medication.
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