a nurse in a mental health facility receives a change of shift report on four clients which of the following clients should the nurse assess first
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?

Correct answer: A

Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.

2. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

Correct answer: C

Rationale: Corrected Rationale: Poor problem-solving ability is a common cognitive symptom of schizophrenia. It affects the client's ability to think clearly and make decisions. Decreased level of consciousness (Choice A) is not a typical assessment finding in schizophrenia. Inability to identify common objects (Choice B) is more indicative of conditions like dementia. Preoccupation with somatic disturbances (Choice D) is characteristic of somatic symptom disorders, not schizophrenia.

3. A nurse enters a patient's room and finds the client pulseless. The living will requests no resuscitation be performed, but the provider has not written the prescription. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. Even though the living will requests no resuscitation, without a written do-not-resuscitate (DNR) order from the provider, the nurse is ethically and legally bound to initiate CPR to provide life-saving measures until further confirmation is obtained. Notifying the family (Choice A) may cause a delay in providing immediate care. Waiting for further instructions (Choice C) can be time-consuming and compromise patient outcomes. Documenting the event (Choice D) is important but should follow after initiating CPR to ensure patient safety and adherence to protocols.

4. A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?

Correct answer: C

Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals. Baby oil (Choice A) is not recommended as it may not provide a sufficient barrier to prevent adherence. Antibiotic ointment (Choice B) is not typically used for this purpose and can sometimes cause irritation. Alcohol wipes (Choice D) are too harsh for the sensitive skin of a newborn and can cause irritation.

5. A nurse is planning care for a client who has chronic kidney disease. Which finding indicates the need for hemodialysis?

Correct answer: C

Rationale: The correct answer is C. A serum creatinine level of 5 mg/dL is significantly elevated and indicates the need for hemodialysis to help filter waste products from the blood. Elevated creatinine levels suggest impaired kidney function and the inability to effectively filter waste from the body. Choices A, B, and D are within normal ranges and do not indicate the need for immediate hemodialysis in a client with chronic kidney disease.

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