ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?
- A. Provide cognitive-behavioral therapy
- B. Offer frequent orientation and reassurance
- C. Administer a sedative to improve memory recall
- D. Refer the client to a neurologist for further evaluation
Correct answer: B
Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.
2. A nurse is caring for a client with thrombocytopenia. Which action is the highest priority to reduce the risk of bleeding?
- A. Use an electric razor instead of a straight razor.
- B. Apply pressure to any bleeding sites for at least 5 minutes.
- C. Avoid invasive procedures unless absolutely necessary.
- D. Monitor for signs of internal bleeding.
Correct answer: C
Rationale: The highest priority action to reduce the risk of bleeding in a client with thrombocytopenia is to avoid invasive procedures unless absolutely necessary. Thrombocytopenia is a condition characterized by a low platelet count, which impairs the blood's ability to clot properly. By avoiding invasive procedures, the nurse minimizes the potential for bleeding episodes that could be challenging to control due to the low platelet count. Using an electric razor instead of a straight razor (Choice A) is a good practice to prevent cuts, but it is not as critical as avoiding invasive procedures in this scenario. Applying pressure to bleeding sites (Choice B) and monitoring for signs of internal bleeding (Choice D) are important interventions but are secondary to the priority of preventing bleeding by avoiding invasive procedures.
3. What side effect should the nurse include in the parent teaching for a child prescribed a baclofen pump for cerebral palsy?
- A. Diarrhea
- B. Hypertonia
- C. Hypotonia
- D. Restlessness
Correct answer: C
Rationale: When a child is prescribed a baclofen pump for cerebral palsy, one of the common side effects to include in parent teaching is hypotonia. Baclofen, a muscle relaxant, can lead to decreased muscle tone, resulting in hypotonia. It is important for parents to be aware of this potential side effect and know how to respond accordingly.
4. The client with a duodenal ulcer may exhibit which of the following findings on assessment?
- A. Hematemesis
- B. Malnourishment
- C. Melena
- D. Pain with eating
Correct answer: C
Rationale: Melena (black, tarry stools) can be an indication of a duodenal ulcer.
5. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?
- A. Amputation
- B. Deep vein thrombosis
- C. Internal bleeding
- D. Kidney failure
Correct answer: Deep vein thrombosis
Rationale:
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