ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?
- A. Administer acetaminophen
- B. Stop the transfusion
- C. Slow the transfusion rate
- D. Administer antihistamines
Correct answer: B
Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.
2. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient?
- A. N95 respirator, gown, gloves, eyewear
- B. Communication signs for droplet precautions
- C. Negative-pressure airflow in room
- D. Communication signs for airborne precautions
Correct answer: A
Rationale: The correct answer is A. Caring for a patient with tuberculosis requires the nurse to use an N95 respirator, gown, gloves, and eyewear to protect against airborne transmission of the disease. Choice B and D are incorrect because while communication signs for precautions are important, the essential items needed for caring for a patient with tuberculosis are personal protective equipment to prevent transmission. Choice C is also incorrect as negative-pressure airflow in the room is a facility-related requirement and not an item carried by the nurse.
3. What is a key characteristic of Illness Anxiety Disorder?
- A. Excessive focus on minor symptoms without medical evidence of illness
- B. The need for consistent reassurance from healthcare professionals
- C. Compulsive behavior to avoid physical illness
- D. Development of avoidance behaviors to reduce anxiety
Correct answer: A
Rationale: The correct answer is A: "Excessive focus on minor symptoms without medical evidence of illness." Illness Anxiety Disorder, formerly known as hypochondriasis, is characterized by a preoccupation with having a serious illness despite no medical evidence to support the presence of an illness. Individuals with this disorder often interpret normal bodily sensations as signs of severe illness. Choice B is incorrect because while individuals with Illness Anxiety Disorder may seek reassurance from healthcare professionals, the excessive focus on minor symptoms is the key characteristic. Choice C is incorrect as compulsive behaviors to avoid physical illness are more characteristic of illnesses like Obsessive-Compulsive Disorder. Choice D is incorrect as the development of avoidance behaviors to reduce anxiety is more commonly seen in conditions like specific phobias or social anxiety disorder.
4. How should the nurse manage the client's pain if a client with a history of substance abuse is requesting pain medication?
- A. Administer the medication as requested
- B. Assess the patient's pain level first
- C. Administer a placebo to the client
- D. Refuse to give any medication to the client
Correct answer: B
Rationale: When a client with a history of substance abuse requests pain medication, the nurse should first assess the patient's pain level. It is important to determine the nature and intensity of the pain before administering any medication to ensure appropriate pain management. Administering medication without assessing the pain level can lead to unnecessary drug administration or inadequate pain relief. Administering a placebo would be unethical and ineffective. Refusing to give any medication without proper assessment can compromise the client's comfort and recovery. Therefore, the correct approach is to assess the patient's pain level first before deciding on the most suitable pain management intervention.
5. A hospice nurse is providing teaching to a client who has a new diagnosis of a terminal illness and her family. Which of the following statements should the nurse include in the teaching?
- A. Hospice care focuses on providing comfort and symptom management.
- B. The provider will coordinate your health care needs while in hospice.
- C. You do not need to choose a family caregiver before being admitted into a hospice facility.
- D. Hospice care continues to help families with grief after a death occurs.
Correct answer: D
Rationale: The correct answer is D because hospice care provides ongoing support to families with grief even after a patient's death. Choice A is incorrect because hospice care focuses on providing comfort and symptom management rather than disease treatment and rehabilitation. Choice B is incorrect as the statement does not accurately reflect the role of a hospice provider. Choice C is incorrect; a family caregiver is not a prerequisite for admission into a hospice facility.
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