ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?
- A. Place a daily calendar in the kitchen
- B. Replace buttoned clothing with zippered items
- C. Replace carpet with hardwood floors
- D. Create variation in the daily routine
Correct answer: A
Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.
2. A nurse on the medical-surgical unit is receiving reports on four clients. Which of the following clients should the nurse assess first?
- A. A client who is receiving warfarin and has an INR of 3.3
- B. A client who has acute kidney injury, creatinine 4 mg/dL, and BUN 52 mg/dL
- C. A client who had an NG tube inserted 6 hours ago and has abdominal distention
- D. A client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat
Correct answer: D
Rationale: The client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat should be assessed first. This client may be experiencing airway obstruction due to hematoma or swelling, making it a priority. Options A, B, and C have concerning findings as well, but airway compromise takes precedence over other issues.
3. A nurse is teaching a group of clients about stress management. Which of the following activities should the nurse recommend to reduce stress?
- A. Watching television
- B. Deep breathing exercises
- C. Drinking coffee
- D. Avoiding exercise
Correct answer: B
Rationale: Deep breathing exercises are effective in reducing stress by promoting relaxation and lowering heart rate, making them a recommended technique. Watching television may not actively reduce stress but can serve as a distraction. Drinking coffee, which contains caffeine, may increase anxiety levels. Avoiding exercise can lead to pent-up stress and tension rather than reducing it.
4. 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.
5. A nurse is caring for a client 4 hours postoperative following a thyroidectomy. The client reports fullness in the throat. What should the nurse assess for?
- A. Hypocalcemia
- B. Hemorrhage
- C. Hypoxia
- D. Hypothyroidism
Correct answer: B
Rationale: In this scenario, the correct answer is B: Hemorrhage. Fullness in the throat post-thyroidectomy can indicate postoperative bleeding, a critical complication that requires immediate assessment and intervention. Choice A, Hypocalcemia, is incorrect because it does not typically present with fullness in the throat. Choice C, Hypoxia, is not directly related to the symptom described and is not the primary concern in this situation. Choice D, Hypothyroidism, is also incorrect as it is a long-term condition and unlikely to manifest suddenly 4 hours postoperatively with throat fullness.
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