ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. How should a healthcare professional assess a patient's pain who is non-verbal?
- A. Looking for changes in vital signs that may indicate pain
- B. Using alternative methods like touch or distraction
- C. Using a pain scale appropriate for non-verbal patients
- D. Observing for facial expressions or other non-verbal cues
Correct answer: A
Rationale: When assessing pain in non-verbal patients, looking for changes in vital signs that may indicate pain is crucial. While using alternative methods like touch or distraction can be helpful, they may not directly indicate the presence of pain. Using a pain scale appropriate for non-verbal patients is important, but it may not always provide immediate feedback. Observing for facial expressions or other non-verbal cues can be subjective and may not always accurately reflect the level of pain the patient is experiencing. Therefore, monitoring vital signs is a more objective way to assess pain in non-verbal patients.
2. Which of the following is an adverse effect of Lithium Carbonate that requires client education?
- A. Increased risk of infection
- B. Gastrointestinal distress
- C. Increased white blood cell count
- D. Nausea and vomiting
Correct answer: B
Rationale: The correct answer is B: Gastrointestinal distress. When taking Lithium Carbonate, clients may experience gastrointestinal distress as an adverse effect. It is crucial to educate clients about this potential side effect to help them manage it effectively. Choices A, C, and D are incorrect. Increased risk of infection (Choice A) is not a typical adverse effect of Lithium Carbonate. Similarly, increased white blood cell count (Choice C) is not associated with this medication's adverse effects. Nausea and vomiting (Choice D) are general side effects of many medications but are not specifically attributed to Lithium Carbonate.
3. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?
- A. Check for signs of deep vein thrombosis.
- B. Assess for compartment syndrome.
- C. Increase the patient's fluid intake.
- D. Prepare the patient for surgery to relieve pain.
Correct answer: B
Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.
4. After surgery, a patient is experiencing pain. What is the nurse's priority action?
- A. Administer pain medication as prescribed.
- B. Assess the patient's pain using a pain scale.
- C. Offer the patient non-pharmacological pain relief methods.
- D. Reassess the patient's pain level after 30 minutes.
Correct answer: B
Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.
5. 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.
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