ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?
- A. Position the client with the affected extremity lower than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.
2. A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?
- A. Alzheimer's disease
- B. Schizophrenia
- C. Substance intoxication
- D. Depression
Correct answer: B
Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.
3. A nurse is teaching a client about the use of fluoxetine. Which of the following should be included?
- A. It can take several weeks for effects to be noticed
- B. It is an antipsychotic medication
- C. It should be taken at night
- D. It has no side effects
Correct answer: A
Rationale: Corrected Rationale: When educating a client about fluoxetine, it is essential to mention that it can take several weeks for the therapeutic effects to be noticed. This is because fluoxetine is an SSRI that requires time to build up in the body and start producing its intended effects. Choice B is incorrect as fluoxetine is not an antipsychotic medication but an SSRI. Choice C is inaccurate because fluoxetine can be taken at any time of the day, and there is no specific requirement to take it at night. Choice D is incorrect as all medications, including fluoxetine, have potential side effects that should be discussed with the client.
4. A nurse is teaching a client about the use of omeprazole. Which of the following should be included?
- A. Take the medication with food
- B. Avoid taking it with NSAIDs
- C. Monitor for gastrointestinal bleeding
- D. It can cause drowsiness
Correct answer: C
Rationale: The correct answer is C. Omeprazole is a proton pump inhibitor that can mask symptoms of gastrointestinal bleeding; clients should be monitored for this. Choices A and B are incorrect because omeprazole is usually taken before meals, and while it is important to avoid NSAIDs if possible due to their effects on the stomach, it is not directly related to omeprazole use. Choice D is also incorrect as omeprazole is not typically associated with causing drowsiness.
5. A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions?
- A. Non-Hodgkin's lymphoma
- B. Endometriosis
- C. Breast cancer
- D. Polycystic ovary syndrome
Correct answer: C
Rationale: Tamoxifen is an anti-estrogen medication primarily used to treat hormone receptor-positive breast cancer. It works by blocking estrogen receptors in breast tissue, slowing the growth of tumors that require estrogen to grow. Choice A, Non-Hodgkin's lymphoma, is incorrect because tamoxifen is not indicated for its treatment. Choice B, Endometriosis, is incorrect as tamoxifen is not used for this condition. Choice D, Polycystic ovary syndrome, is also incorrect since tamoxifen is not a treatment for this syndrome.
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