a nurse is caring for a client who has mild anxiety which of the following findings should the nurse expect
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.

2. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

Correct answer: A

Rationale: Bladder distention is the correct sign of catheter occlusion. When a catheter is occluded, the urine cannot drain properly, leading to the buildup of urine in the bladder and subsequent distention. Frequent urination, dark urine, and increased thirst are not typical signs of catheter occlusion. Frequent urination can be a sign of conditions like urinary tract infection, dark urine may indicate dehydration or other issues, and increased thirst can be related to various factors like diabetes or medication side effects.

3. A community health nurse is reviewing primary prevention for West Nile virus with a group of patients in a rural health clinic. What instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Eliminate areas of standing water.' Standing water provides breeding grounds for mosquitoes, which spread West Nile virus. By eliminating standing water, individuals can reduce the risk of mosquito breeding and the transmission of the virus. Choices B, C, and D are incorrect. Wearing a mask when outdoors, ensuring food is cooked thoroughly, and avoiding contact with sick individuals are not directly related to primary prevention strategies for West Nile virus.

4. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?

Correct answer: A

Rationale: The correct answer is A. Tying wrist restraints to the bed rails is a safety hazard because if the bed rails are lowered, the restraints can tighten and cause injury or asphyxiation. Choice B, placing a bedside table across the foot of the bed, may not be ideal for convenience but does not pose a direct safety hazard. Choice C, leaving a meal tray at the bedside from breakfast, is more of an infection control issue than an immediate safety hazard. Choice D, having a call light extension cord pinned to the bedspread, is also not a direct safety hazard unless it poses a risk of entanglement or tripping, which is not indicated in the scenario.

5. A nurse in the telemetry unit is receiving the laboratory findings for an adult male client who is being treated for a myocardial infarction. Which of the following is an expected finding for the client?

Correct answer: A

Rationale: The correct answer is A. Troponin I is a specific marker for myocardial infarction, and levels of 8 ng/mL are elevated, indicating heart muscle damage. Brain natriuretic peptide (BNP) is more related to heart failure rather than myocardial infarction, making choice B incorrect. Alanine aminotransferase (ALT) is a liver enzyme and not specific to myocardial infarction, so choice C is incorrect. High-density lipoprotein (HDL) is a type of cholesterol and is not typically used to diagnose or monitor myocardial infarction, making choice D incorrect.

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