ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. Which of the following best describes a somatic symptom disorder?
- A. Client experiences sudden onset of symptoms due to stress
- B. Physical manifestations occur due to underlying medical conditions
- C. Client has excessive preoccupation with physical symptoms without a medical cause
- D. Client avoids medical care due to fear of receiving a diagnosis
Correct answer: C
Rationale: The correct answer is C. Somatic symptom disorder is characterized by individuals having excessive preoccupation with physical symptoms that may or may not have an identifiable medical cause. Choice A is incorrect because the sudden onset of symptoms due to stress is more indicative of acute stress reaction. Choice B is incorrect as it describes physical manifestations related to known medical conditions, not somatic symptom disorder. Choice D is incorrect as it relates to health anxiety or illness anxiety disorder, where individuals avoid seeking medical care due to fear of receiving a diagnosis.
2. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?
- A. Encourage physical activity to reduce withdrawal symptoms
- B. Administer diazepam to prevent seizures
- C. Monitor for signs of dehydration
- D. Encourage the client to verbalize their feelings
Correct answer: B
Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.
3. A client reports pain and swelling at the IV site. What should the nurse do first?
- A. Flush the IV line and continue the infusion.
- B. Stop the infusion and notify the healthcare provider.
- C. Increase the IV infusion rate to reduce discomfort.
- D. Apply a warm compress to the IV site and continue monitoring.
Correct answer: B
Rationale: The correct answer is B: Stop the infusion and notify the healthcare provider. Pain and swelling at an IV site can indicate infiltration or infection, which are serious complications. Stopping the infusion helps prevent further harm to the client, and notifying the healthcare provider promptly allows for appropriate assessment and intervention. Choice A is incorrect because flushing the IV line and continuing the infusion could exacerbate the issue. Choice C is incorrect as increasing the IV infusion rate is not the appropriate action for pain and swelling at the site. Choice D is incorrect because applying a warm compress may not address the underlying issue of infiltration or infection; it's crucial to stop the infusion and seek further guidance.
4. A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?
- A. Diarrhea
- B. Vomiting
- C. Ringing in ears
- D. Dizziness
Correct answer: B
Rationale: The correct answer is B: Vomiting. Vomiting is a common sign of digoxin toxicity and should be reported to the healthcare provider. Diarrhea (Choice A) is a more common side effect of digoxin but not typically associated with toxicity. Ringing in the ears (Choice C) is a potential sign of toxicity; however, vomiting is a more immediate concern. Dizziness (Choice D) can occur with digoxin use but is not a specific indicator of toxicity.
5. A nurse is assigned to care for four clients. Which client should the nurse assess first?
- A. A client with chest pain and shortness of breath
- B. A client with a fever of 100°F
- C. A client scheduled for surgery
- D. A client with stable vital signs
Correct answer: A
Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.
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