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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is assessing a client who is at risk for falls. Which of the following findings should the nurse recognize as increasing the client's risk of falling?
- A. Normal gait
- B. Recent history of dizziness
- C. 20/20 vision
- D. Takes a multivitamin daily
Correct answer: B
Rationale: The correct answer is B: Recent history of dizziness. A recent history of dizziness significantly increases the risk of falling, as dizziness can impair balance and coordination. Having a normal gait (choice A) and 20/20 vision (choice C) are not factors that directly increase the risk of falling. Taking a multivitamin daily (choice D) does not inherently contribute to an increased risk of falling unless it causes dizziness as a side effect, which is not specified in the question.
2. A client has been prescribed ferrous sulfate. Which instruction should the nurse include?
- A. Take with meals
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with milk
Correct answer: B
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with a glass of orange juice. Vitamin C, found in orange juice, enhances the absorption of iron, making it more effective. Taking ferrous sulfate with meals, at bedtime, or with milk can decrease its absorption and effectiveness, so these options are incorrect.
3. A nurse is teaching a group of clients about stress management. Which of the following activities should the nurse recommend to reduce stress?
- A. Watching television
- B. Deep breathing exercises
- C. Drinking coffee
- D. Avoiding exercise
Correct answer: B
Rationale: Deep breathing exercises are effective in reducing stress by promoting relaxation and lowering heart rate, making them a recommended technique. Watching television may not actively reduce stress but can serve as a distraction. Drinking coffee, which contains caffeine, may increase anxiety levels. Avoiding exercise can lead to pent-up stress and tension rather than reducing it.
4. A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?
- A. Decreased deep tendon reflexes
- B. Increased blood pressure
- C. Tachypnea
- D. Hyperreflexia
Correct answer: A
Rationale: The correct answer is A: Decreased deep tendon reflexes. In a client receiving magnesium sulfate for preeclampsia, decreased deep tendon reflexes indicate magnesium toxicity. Magnesium toxicity can lead to respiratory depression and other serious complications, requiring immediate intervention. Choices B, C, and D are incorrect because increased blood pressure, tachypnea, and hyperreflexia are not typical findings associated with magnesium toxicity.
5. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?
- A. Sudden weight loss
- B. Regular contractions
- C. Shortness of breath
- D. Vaginal spotting
Correct answer: B
Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.
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