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?
- A. Feelings of dread
- B. Rapid speech
- C. Purposeless activity
- D. Heightened perceptual field
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 client with type 1 DM is being taught about hypoglycemia by a nurse. Which statement by the client indicates an understanding of the teaching?
- A. “Exercise decreases the risk of hypoglycemia.”
- B. “I should skip my insulin if I don't eat.”
- C. “I can drink 4 oz of regular soda if my blood sugar is low.”
- D. “Oral diabetic medications do not lead to hypoglycemia; only insulin does.”
Correct answer: C
Rationale: The correct answer is C because the client should have a quick-acting source of 15 g of carbohydrates to treat hypoglycemic episodes, such as 4 oz of regular soda. Choice A is incorrect because while exercise can help manage blood sugar levels, it can also increase the risk of hypoglycemia if not properly managed. Choice B is incorrect as skipping insulin when not eating can lead to hyperglycemia, not prevent hypoglycemia. Choice D is incorrect because certain oral diabetic medications can indeed cause hypoglycemia, not just insulin.
3. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement: “When the cat’s away, the mice will play.” The client responds, “The mice come out when the cat is not around.” The nurse should document this finding as:
- A. Echolalia
- B. Associative looseness
- C. Neologisms
- D. Concrete thinking
Correct answer: D
Rationale: The client’s literal interpretation of the statement is an example of concrete thinking, a cognitive symptom often seen in schizophrenia where abstract thinking is impaired. Choice A, Echolalia, is the repetition of words spoken by others, which is not demonstrated in this scenario. Choice B, Associative looseness, refers to a disturbance in the logical progression of thoughts, leading to a disorganized thought process. Choice C, Neologisms, involves creating new words or phrases with unique meanings, which is not evident in the client's response.
4. A nurse is teaching a client about the use of pantoprazole. Which of the following should be included?
- A. It should be taken on an empty stomach
- B. It reduces stomach acid production
- C. It can cause headache
- D. It should not be used with other antacids
Correct answer: C
Rationale: The correct information to include when teaching a client about pantoprazole is that it can cause headaches. Option A is incorrect because pantoprazole is usually taken before meals. Option B is not necessary information for the client to know. Option D is not directly related to the side effects of pantoprazole.
5. A nurse is caring for a client with Alzheimer’s disease. Which action should the nurse include in the plan of care to support the client’s cognitive function?
- A. Place a daily calendar in the kitchen
- B. Replace buttoned clothing with zippered items
- C. Replace the carpet with hardwood floors
- D. Create variation in the daily routine
Correct answer: A
Rationale: Placing a daily calendar in the kitchen is essential to help clients with Alzheimer's stay oriented to time and maintain cognitive function. It supports their ability to recall the day, date, and upcoming events, promoting a sense of control over their environment. Choices B, C, and D do not directly target cognitive function support in clients with Alzheimer's disease. While replacing buttoned clothing with zippered items may aid in dressing independently, changing the flooring or introducing variation in the daily routine does not specifically address cognitive function support.
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