LPN LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A menopausal client is having difficulty getting to sleep and asks what actions she should incorporate into her daily routine to promote sleep. The nurse would encourage which of the following measures to promote sleep?
- A. Consume a warm drink at bedtime
- B. Take an evening walk before bedtime
- C. Take an afternoon nap
- D. Limit alcohol and nicotine prior to bedtime
Correct answer: D
Rationale: The correct answer is D: Limit alcohol and nicotine prior to bedtime. Alcohol and nicotine are stimulants that can disrupt sleep patterns, so avoiding them before bedtime can promote better sleep. Choices A, B, and C are incorrect. Consuming a warm drink at bedtime may lead to frequent urination, disrupting sleep; taking an evening walk before bedtime may increase alertness rather than inducing sleep; and taking an afternoon nap can make it harder to fall asleep at night.
2. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?
- A. Nausea and vomiting
- B. Increased urination
- C. Tremors
- D. Blurred vision
Correct answer: C
Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.
3. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?
- A. Fever
- B. Rash
- C. Fatigue
- D. Increased appetite
Correct answer: B
Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.
4. A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?
- A. Place the bed in the lowest position, instruct the patient to remain in bed, ensure the bedside table is within reach.
- B. Instruct the patient to use the call light, apply an ambulation alarm to the patient’s leg, check on the patient hourly.
- C. Assign a sitter to monitor the patient, raise the bed rails, provide the patient with a call button.
- D. Check on the patient every two hours, provide verbal reminders to use the call light, lock the bed wheels.
Correct answer: B
Rationale: In this scenario, the correct actions for the nurse to take involve ensuring patient safety and fall prevention measures. Choice B is the correct answer because instructing the patient to use the call light allows them to signal for help, applying an ambulation alarm helps detect movement, and checking on the patient hourly increases monitoring frequency. These actions are essential for preventing falls in a disoriented patient with a history of falls. Choices A, C, and D are incorrect: A does not provide adequate monitoring or fall prevention measures, C relies solely on assigning a sitter without utilizing technological aids, and D lacks continuous monitoring and specific fall prevention strategies.
5. A client is being educated by a nurse about the use of carbidopa-levodopa. Which of the following should be included?
- A. It will cure Parkinson's disease
- B. Monitor for dyskinesia
- C. It can be taken with food
- D. It is an opioid medication
Correct answer: B
Rationale: The correct answer is to 'Monitor for dyskinesia.' Carbidopa-levodopa can cause dyskinesia as a side effect, characterized by involuntary movements. Monitoring for this side effect is crucial. Choice A is incorrect because carbidopa-levodopa helps manage symptoms of Parkinson's disease but does not cure it. Choice C is incorrect because carbidopa-levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect because carbidopa-levodopa is not an opioid medication.
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