a nurse is caring for an older adult who has a non palpable skin lesion that is less than 05 cm in diameter which term should the nurse use to documen
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ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.

2. When teaching a client about the use of lisinopril, which of the following should be included?

Correct answer: A

Rationale: The correct answer is A. Lisinopril is an ACE inhibitor, and a common side effect associated with its use is a persistent cough. This is important information that the client should be aware of. Choice B is incorrect because lisinopril is not a calcium channel blocker, it is an ACE inhibitor. Choice C is incorrect as lisinopril is not considered safe during pregnancy, especially during the second and third trimesters as it can cause harm to the fetus. Choice D is incorrect because lisinopril is typically recommended to be taken on an empty stomach, about an hour before meals.

3. A healthcare professional is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client?

Correct answer: C

Rationale: A BMI of 25-29.9 is considered overweight. Therefore, a BMI of 25 correlates with an overweight client. A BMI of 18.5-24.9 indicates a healthy weight. Choices A, B, and D are incorrect as they fall into the healthy weight or obese categories, not overweight.

4. A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following factors is strongly associated with this postpartum complication?

Correct answer: A

Rationale: The correct answer is A: Cesarean birth. Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors for DVT include smoking, obesity, and a history of thromboembolism. Vaginal birth, anemia, and multiparity are not strongly associated with an increased risk of deep-vein thrombosis postpartum. It is important to educate clients undergoing cesarean birth about the increased risk of DVT and measures to prevent it, such as early ambulation and the use of compression stockings.

5. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

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