ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is preparing to teach a client about the management of hypoglycemia. Which sign should the nurse instruct the client to monitor for?
- A. Diaphoresis
- B. Polyuria
- C. Abdominal pain
- D. Thirst
Correct answer: A
Rationale: The correct answer is A: Diaphoresis. Diaphoresis, which refers to excessive sweating, is a classic symptom of hypoglycemia. Instructing the client to monitor for diaphoresis is crucial as it can help them recognize and address hypoglycemic events promptly. Polyuria (excessive urination), abdominal pain, and thirst are not typical signs of hypoglycemia. Polyuria is more commonly associated with conditions like diabetes mellitus, while abdominal pain and thirst are not specific indicators of low blood sugar levels.
2. A nurse is caring for a client who is in the third trimester of pregnancy and has gestational diabetes. Which of the following complications is the fetus at risk for?
- A. Macrosomia
- B. Hydrocephalus
- C. Cleft palate
- D. Spina bifida
Correct answer: A
Rationale: The correct answer is A: Macrosomia. Gestational diabetes can result in fetal macrosomia, a condition where the baby grows larger than normal due to excess glucose in the mother's blood. This increases the risk of complications during delivery. Choices B, C, and D are incorrect. Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain. Cleft palate is a congenital condition where there is a split or opening in the roof of the mouth. Spina bifida is a neural tube defect characterized by the incomplete development of the spinal cord or its coverings.
3. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend?
- A. Low potassium diet
- B. High fiber diet
- C. Low fat diet
- D. Low sodium diet
Correct answer: C
Rationale: The correct answer is C: 'Low fat diet.' A client with chronic cholecystitis should follow a low-fat diet to decrease the frequency of biliary colic episodes. Fats can trigger the release of cholecystokinin, which stimulates the gallbladder to contract, potentially causing pain in individuals with cholecystitis. Choices A, B, and D are incorrect. A low potassium diet is prescribed for individuals with specific kidney conditions or on certain medications. A high fiber diet is beneficial for conditions like constipation, diverticulosis, or to promote general bowel health. A low sodium diet is often recommended for conditions like hypertension or heart failure to reduce fluid retention.
4. A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?
- A. Decrease fluid intake.
- B. Chew sugarless gum.
- C. Avoid using mouthwash.
- D. Increase intake of dairy products.
Correct answer: B
Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.
5. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
- A. Assault
- B. Battery
- C. Negligence
- D. False imprisonment
Correct answer: C
Rationale: The correct answer is C: Negligence. Negligence refers to the failure to take reasonable care or fulfill a duty, which can cause harm to others. In this scenario, the nurse's failure to notify the provider of a change in the client's condition constitutes negligence as it breaches the standard of care expected in healthcare practice. Choice A, Assault, involves the threat of harmful or offensive contact, which is not applicable in this situation. Choice B, Battery, refers to the intentional harmful or offensive touching of another person without their consent, which is also not relevant here. Choice D, False imprisonment, involves the intentional confinement or restraint of an individual against their will, which is not the issue described in the scenario. Therefore, the most appropriate tort in this case is negligence.
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