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PN ATI Capstone Fundamentals Quiz
1. A healthcare professional is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare professional use?
- A. Numeric rating scale
- B. Behavioral indicators
- C. Visual analog scale
- D. Faces pain scale
Correct answer: B
Rationale: For clients with dementia who have difficulty communicating, assessing pain using behavioral indicators like increased agitation and restlessness is more effective than relying on self-reported scales such as numeric rating scale, visual analog scale, or faces pain scale. Behavioral indicators provide valuable insights into pain perception in individuals who may have challenges expressing themselves verbally.
2. A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?
- A. I should wear my slippers whenever I am out of bed
- B. I can walk barefoot at home
- C. I should apply lotion between my toes
- D. I can soak my feet in warm water
Correct answer: A
Rationale: The correct answer is A. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it protects the feet from injury. Walking barefoot, as mentioned in option B, can increase the risk of cuts, sores, and infections in diabetic patients. Applying lotion between the toes, as stated in option C, can lead to maceration and increase the risk of fungal infections. Similarly, soaking feet in warm water, as mentioned in option D, can cause skin breakdown and should be avoided by diabetic patients.
3. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct answer: B
Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.
4. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.
5. When admitting a client with fever, confusion, and decreased level of consciousness, what should the nurse do first after obtaining the client's history and assessment?
- A. Identify the client's needs
- B. Start intravenous fluids
- C. Notify the provider
- D. Conduct a neurological assessment
Correct answer: A
Rationale: When a client presents with fever, confusion, and decreased level of consciousness, the first step should be to identify the client's needs. This involves recognizing any immediate concerns or issues that require urgent attention. Starting intravenous fluids, notifying the provider, or conducting a neurological assessment may be necessary actions but should come after identifying the client's needs to ensure proper prioritization of care.
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