ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What is the primary focus of secondary prevention in community mental health care?
- A. Teaching stress-reduction techniques
- B. Early detection of mental illness
- C. Leading support groups for clients with substance use disorder
- D. Rehabilitation and prevention of further issues
Correct answer: B
Rationale: The correct answer is B: Early detection of mental illness. Secondary prevention in community mental health care focuses on identifying mental health issues at an early stage to provide timely interventions. Choice A, teaching stress-reduction techniques, is more aligned with primary prevention aimed at preventing the onset of mental health problems. Choice C, leading support groups for clients with substance use disorder, pertains more to providing specific interventions for individuals with substance use issues rather than the general focus of secondary prevention. Choice D, rehabilitation and prevention of further issues, is more related to tertiary prevention, which involves addressing existing mental health conditions and preventing complications or recurrence.
2. A client requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I had a bowel movement, but I was able to save the urine.''
- B. ''I have a specimen in the bathroom from about 30 minutes ago.''
- C. ''I drink a lot, so I will fill up the bottle and complete the test quickly.''
- D. ''I flushed what I urinated at 7:00 a.m. and have saved all urine since.''
Correct answer: C
Rationale: Option C demonstrates an understanding of the need to collect urine over 24 hours. The client's statement shows awareness that increased fluid intake will help in filling up the collection bottle quickly, which is essential for an accurate test result. This choice reflects the correct understanding of the teaching. Options A, B, and D do not reflect the necessary comprehension for a 24-hr urine collection process. Option A involves a bowel movement, which is not relevant to a urine collection. Option B only mentions a specimen from 30 minutes ago, not over a 24-hour period. Option D indicates flushing urine, which contradicts the idea of saving all urine for the test.
3. What is the best intervention for a patient experiencing severe hypoglycemia?
- A. Administer IV dextrose
- B. Administer oral glucose
- C. Monitor blood sugar levels
- D. Recheck blood sugar in 15 minutes
Correct answer: A
Rationale: The best intervention for a patient experiencing severe hypoglycemia is to administer IV dextrose. This intervention is necessary to rapidly raise blood sugar levels in critical situations. Administering oral glucose may not be effective in severe cases as the patient may be unable to consume it. Monitoring blood sugar levels and rechecking blood sugar in 15 minutes are important steps but not the initial best intervention for severe hypoglycemia.
4. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
- A. Monitor the client's IV site for thrombophlebitis.
- B. Administer flumazenil to the client.
- C. Evaluate the client for further suicidal behavior.
- D. Initiate seizure precautions for the client.
Correct answer: B
Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.
5. When explaining suicide precautions to a client, what would be the best explanation?
- A. You need to control yourself. If you cannot, we will do it for you.
- B. This can seem embarrassing, but we want you to be safe.
- C. You will stay on these precautions for one week.
- D. When you feel you are safer, then we will not need to observe you.
Correct answer: D
Rationale: Choice D provides a supportive and empowering explanation to the client on suicide precautions. It emphasizes the client's own sense of safety and control, indicating that the observation is temporary and can be removed when the client feels safer. This approach promotes autonomy and encourages the client to actively participate in their own well-being, fostering a therapeutic relationship based on trust and collaboration.
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