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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. What is the first action when a client who is admitted with schizophrenia reports hearing voices telling them to harm themselves?
- A. Administer antipsychotic medication
- B. Ask the client what the voices are saying
- C. Distract the client with another activity
- D. Call the healthcare provider
Correct answer: B
Rationale: The correct first action when a client with schizophrenia reports hearing voices telling them to harm themselves is to ask the client what the voices are saying. This is important to assess the content of the hallucinations and determine if there is any immediate danger or suicidal intent. Administering antipsychotic medication without knowing the content of the voices or the level of danger could be inappropriate and potentially harmful. Distracting the client with another activity may not address the underlying issue of the hallucinations commanding harm. Calling the healthcare provider can be done after assessing the situation and gathering information from the client.
2. A client in the second trimester of pregnancy asks how to treat constipation. Which of the following should the nurse recommend?
- A. Decrease intake of vitamins and supplements to every other day
- B. Eat 15 g of fiber per day
- C. Consume 48 ounces of water daily
- D. Drink hot water with lemon juice each morning
Correct answer: D
Rationale: The correct answer is D: Drink hot water with lemon juice each morning. Drinking hot water with lemon juice can help stimulate bowel movements, making it a natural and safe recommendation for pregnant clients experiencing constipation. Choice A is incorrect because reducing vitamin and supplement intake may not directly address constipation. Choice B, eating 15 g of fiber per day, could be helpful but may not be as effective as the correct answer for immediate relief. Choice C, consuming 48 ounces of water daily, is essential for overall health but may not be as directly effective as the correct answer in alleviating constipation.
3. A nurse is reviewing the medication metformin with a client who has diabetes. Which of the following side effects should the nurse discuss?
- A. Gastrointestinal upset
- B. Increased appetite
- C. Weight loss
- D. Frequent urination
Correct answer: A
Rationale: The correct answer is A: Gastrointestinal upset. Metformin can cause gastrointestinal upset, especially when first starting therapy. It is important to take it with food to reduce these effects. Increased appetite (choice B) and weight loss (choice C) are not common side effects of metformin but may occur due to improved blood sugar control. Frequent urination (choice D) is a symptom of uncontrolled diabetes and not a side effect of metformin.
4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?
- A. Offer advice on coping strategies
- B. Encourage the partner to ask for help when needed
- C. Discuss the importance of grieving alone
- D. Suggest the partner avoid talking about the loss
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.
5. A healthcare professional is preparing to administer morphine for severe pain. What is the priority assessment the professional should make before administration?
- A. Blood pressure
- B. Respiratory rate
- C. Heart rate
- D. Temperature
Correct answer: B
Rationale: Before administering morphine, the priority assessment the healthcare professional should make is the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to prevent any potential complications. Assessing blood pressure, heart rate, and temperature are important as well, but they are not the priority when administering morphine for severe pain.
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