a nurse is caring for a client in a mental health facility the clients daughter is crying and tells the nurse that she feels guilty for leaving her fa
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

1. A nurse is caring for a client in a mental health facility. The client’s daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response?

Correct answer: A

Rationale: The correct response is A: 'I’d like to know more about what’s bothering you.' Encouraging the daughter to express her feelings allows her to explore her emotions, which can be helpful in addressing her guilt and providing emotional support. Choice B is not as open-ended and may come across as confrontational. Choice C may invalidate the daughter's feelings of guilt by implying she shouldn't feel that way. Choice D assumes the father's emotions and may not address the daughter's feelings of guilt effectively.

2. A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Massaging the injection site can lead to bruising or discomfort and should be avoided. Instructing the client not to breastfeed while on heparin is inaccurate, as heparin does not pass into breast milk in significant amounts. Aspirin is contraindicated for clients on heparin due to the increased risk of bleeding, so requesting a prescription for PRN aspirin would not be appropriate in this situation.

3. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

Correct answer: D

Rationale: When preparing a client for transfer to another unit, the nurse should include all the findings mentioned in the choices in the transfer report. It is crucial to document the client's response to pain medication as it helps the receiving unit manage the client's pain effectively. Reviewing the ongoing discharge plan ensures that the client's care continues seamlessly after the transfer. Noting recent physical changes is vital for the receiving unit to monitor the client's condition accurately. Therefore, all of the above findings are essential for ensuring continuity of care and providing comprehensive information to the receiving unit.

4. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?

Correct answer: A

Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.

5. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B because shortness of breath is an indication of transplant rejection, along with other manifestations like fatigue, edema, bradycardia, and hypotension. Choice A is incorrect because immunosuppressant medications are usually taken for life to prevent rejection. Choice C is incorrect as the surgical site may take longer to heal fully. Choice D is incorrect as the initiation of exercise post-heart transplant should be gradual and individualized based on the client's condition.

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