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PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is caring for a client who has liver cirrhosis and ascites. Which of the following actions should the nurse take to monitor the effectiveness of the treatment?
- A. Measure the client’s abdominal girth daily
- B. Monitor the client’s hemoglobin level
- C. Administer lactulose as prescribed
- D. Weigh the client weekly
Correct answer: A
Rationale: Measuring the client’s abdominal girth daily is the most effective way to monitor the reduction of ascites and fluid retention in clients with liver cirrhosis. This measurement helps assess the effectiveness of treatment in managing ascites by monitoring changes in abdominal size. Monitoring the client’s hemoglobin level (Choice B) is not directly related to assessing the effectiveness of ascites treatment. Administering lactulose as prescribed (Choice C) is important in managing hepatic encephalopathy, not ascites. Weighing the client weekly (Choice D) may not provide real-time feedback on the reduction of ascites compared to daily abdominal girth measurements.
2. A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching?
- A. If I eat 500 fewer calories per day, I should lose 1 pound per week.
- B. If I eat 450 fewer calories per day, I should lose 2 pounds per week.
- C. If I eat 250 fewer calories per day, I should lose 2 pounds per week.
- D. If I eat 300 fewer calories per day, I should lose 1 pound per week.
Correct answer: A
Rationale: The correct answer is A: 'If I eat 500 fewer calories per day, I should lose 1 pound per week.' This statement is accurate because a reduction of 500 calories per day typically results in a weight loss of 1 pound per week. This is based on the principle that a calorie deficit of 3,500 calories equals about 1 pound of body fat. Choices B, C, and D are incorrect because they do not align with the established relationship between calorie reduction and weight loss. Eating 450 fewer calories per day would not lead to a weight loss of 2 pounds per week; similarly, reducing calories by 250 or 300 per day would not result in losing 2 pounds or 1 pound per week, respectively.
3. A nurse is planning care for a client who has Parkinson’s disease and is at risk for aspiration. Which of the following actions should the nurse include in the plan of care?
- A. Encourage the client to eat thin liquids
- B. Instruct the client to tilt their head forward when swallowing
- C. Give the client large pieces of food
- D. Have the client lie down after meals
Correct answer: B
Rationale: The correct action the nurse should include in the plan of care for a client with Parkinson’s disease at risk for aspiration is to instruct the client to tilt their head forward when swallowing. This action helps protect the airway and reduces the risk of aspiration in clients with impaired swallowing, which is common in Parkinson’s disease. Encouraging the client to eat thin liquids (Choice A) can increase the risk of aspiration as they are harder to control during swallowing. Giving the client large pieces of food (Choice C) can also increase the risk of choking and aspiration. Having the client lie down after meals (Choice D) can further increase the risk of aspiration due to the potential for reflux. Therefore, the best action to prevent aspiration in this situation is to instruct the client to tilt their head forward when swallowing.
4. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
- A. Butterfly rash on the face
- B. Weight gain
- C. Joint deformities
- D. Increased hair growth
Correct answer: A
Rationale: The correct answer is A: Butterfly rash on the face. A butterfly-shaped rash across the nose and cheeks is a classic symptom of systemic lupus erythematosus (SLE), an autoimmune disease. Weight gain (Choice B) is not typically associated with SLE. Joint deformities (Choice C) are more commonly seen in conditions like rheumatoid arthritis. Increased hair growth (Choice D) is not a typical finding in SLE.
5. A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?
- A. Decrease fluid intake.
- B. Chew sugarless gum.
- C. Avoid using mouthwash.
- D. Increase intake of dairy products.
Correct answer: B
Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.
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