ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. Which of the following is a common manifestation of opioid withdrawal?
- A. Bradycardia and hypotension
- B. Tremors and increased blood pressure
- C. Severe muscle weakness and fatigue
- D. Severe hallucinations and delusions
Correct answer: B
Rationale: The correct answer is B: Tremors and increased blood pressure. During opioid withdrawal, individuals commonly experience symptoms such as tremors, increased blood pressure, and restlessness. Choice A, which suggests bradycardia and hypotension, is incorrect as opioid withdrawal often leads to tachycardia (rapid heart rate) and increased blood pressure. Choice C, severe muscle weakness and fatigue, is not a typical manifestation of opioid withdrawal. Choice D, severe hallucinations and delusions, is more characteristic of conditions like delirium tremens associated with alcohol withdrawal, rather than opioid withdrawal.
2. What are the expected manifestations in a patient experiencing a thrombotic stroke?
- A. Sudden numbness or loss of function on one side of the body
- B. Sudden loss of consciousness and seizure
- C. Gradual onset of difficulty speaking
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: The correct manifestation in a patient experiencing a thrombotic stroke is sudden numbness or loss of function on one side of the body. This is due to the blockage of a blood vessel by a clot, leading to a lack of blood flow to a specific part of the brain. Choices B, C, and D are incorrect. Sudden loss of consciousness and seizure are more commonly associated with hemorrhagic strokes. Gradual onset of difficulty speaking is often seen in ischemic strokes affecting language areas, not specifically in thrombotic strokes. Loss of sensation in the affected limb is more indicative of sensory nerve damage rather than the motor deficits seen in thrombotic strokes.
3. A client with cirrhosis is about to receive a dose of lactulose. The client questions the need for the medication, stating they are not constipated. The nurse should explain that lactulose is used in cirrhosis to reduce levels of which component in the bloodstream?
- A. Glucose
- B. Ammonia
- C. Potassium
- D. Bicarbonate
Correct answer: B
Rationale: Lactulose is administered to clients with cirrhosis to lower blood ammonia levels, thus aiding in the prevention of hepatic encephalopathy. Elevated ammonia levels in cirrhosis can lead to cognitive impairment and hepatic encephalopathy. Therefore, the correct answer is B (Ammonia). Glucose (Choice A) is not the component targeted by lactulose in cirrhosis. Potassium (Choice C) and Bicarbonate (Choice D) are not directly affected by lactulose administration in cirrhosis.
4. During an assessment, an older adult client's son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
- A. Bradycardia
- B. Night sweats
- C. Confusion
- D. Narrowed pulse pressure
Correct answer: Confusion
Rationale: Confusion is a common manifestation of pneumonia in older adults. It can result from inadequate oxygenation to the brain due to respiratory compromise. Bradycardia, night sweats, and narrowed pulse pressure are not typically specific findings associated with pneumonia and should be further assessed or monitored, but confusion is a key indicator that warrants immediate attention.
5. A group of clients is being instructed by a nurse regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates?
- A. Milk, eggs, and cheese
- B. Butter, oils, and avocados
- C. Rice, potatoes, and oranges
- D. Chicken, green beans, and apples
Correct answer: Rice, potatoes, and oranges
Rationale: The correct answer is C: Rice, potatoes, and oranges. These foods are rich in carbohydrates. Choice A (Milk, eggs, and cheese) contains minimal carbohydrates as they are primarily sources of protein and fat. Choice B (Butter, oils, and avocados) contains very little to no carbohydrates as they are high in fats. Choice D (Chicken, green beans, and apples) also contains minimal carbohydrates, with protein and fiber being more prominent in these foods.
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