ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Poor problem-solving ability
- D. Preoccupation with somatic disturbances
Correct answer: C
Rationale: In clients with schizophrenia, poor problem-solving ability is a common assessment finding due to impaired cognitive function associated with the disorder. This impairment can manifest as difficulties in decision-making and problem-solving. Choice A, decreased level of consciousness, is not a typical finding in schizophrenia. Choice B, inability to identify common objects, is more indicative of conditions like dementia rather than schizophrenia. Choice D, preoccupation with somatic disturbances, is more characteristic of somatic symptom disorder rather than schizophrenia.
2. A nurse is caring for a client with a prescription for duloxetine. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum electrolytes
- C. Blood glucose
- D. Potassium levels
Correct answer: A
Rationale: The correct answer is A) Liver function. Duloxetine can affect liver function, making it crucial for the nurse to monitor liver function tests. Monitoring serum electrolytes (choice B), blood glucose (choice C), or potassium levels (choice D) is not directly associated with duloxetine use and would not be the priority in this case.
3. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct answer: A
Rationale: The correct answer is A: Paradoxical pulse. Paradoxical pulse, which is a significant drop in systolic blood pressure during inspiration, indicates cardiac tamponade, a life-threatening complication of pericarditis. This finding requires immediate attention as it suggests potential compromised cardiac function. Choices B, C, and D are associated with pericarditis but do not indicate the same level of urgency as paradoxical pulse.
4. While caring for a client receiving oxytocin for labor augmentation, the nurse notes contractions occurring every 45 seconds and lasting 90 seconds. What should the nurse do?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Apply an internal fetal monitor
- D. Administer an analgesic
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, which can lead to fetal distress and complications. By stopping the oxytocin, the nurse can help regulate contractions and prevent harm to the fetus. Increasing the oxytocin infusion would exacerbate the issue by further intensifying contractions. Applying an internal fetal monitor may be necessary for closer monitoring but is not the immediate action required. Administering an analgesic is not appropriate in this scenario as the primary concern is addressing the uterine hyperstimulation caused by oxytocin.
5. A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?
- A. Stomatitis
- B. Fatigue
- C. Wasting syndrome
- D. Lipodystrophy
Correct answer: B
Rationale: The correct answer is B: Fatigue. A client with early HIV infection can be asymptomatic or experience symptoms like viral infections, such as fever, rash, and fatigue. Fatigue is a common early manifestation of HIV infection due to the body's immune response. Stomatitis (choice A) is more commonly associated with oral health issues or infections. Wasting syndrome (choice C) and lipodystrophy (choice D) are more advanced manifestations seen in later stages of HIV infection, characterized by severe weight loss and changes in body fat distribution, respectively.
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