ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?
Correct Answer: D
Rationale: The correct answer is D: Excessive sweating. Serotonin syndrome is a serious condition caused by excessive serotonin levels in the body. Excessive sweating is a key symptom of serotonin syndrome, indicating autonomic instability. This can lead to a potentially life-threatening situation if not promptly addressed. Dry mouth (
A), constipation (
B), and insomnia (
C) are common side effects of sertraline but are not indicative of serotonin syndrome. It is crucial to educate the client to monitor and report excessive sweating to prevent the progression of serotonin syndrome.
Question 2 of 5
A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like 'something opened up.' The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Cover the wound with a saline-soaked dressing. This action is appropriate because it helps to prevent further damage to the exposed intestinal tissue and maintains a moist environment to promote healing. Placing the client in Trendelenburg position (
A) is not recommended as it can increase intra-abdominal pressure and worsen the situation. Reinserting the protruding intestinal tissue (
B) should not be done by the nurse as it can lead to complications and is beyond the scope of nursing practice. Monitoring vital signs every 30 minutes (
D) is important but not the immediate priority in this situation where wound coverage is crucial.
Question 3 of 5
A nurse in an acute mental health facility is teaching a client about the potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might feel lightheaded, but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D: Veracity. Veracity pertains to truthfulness and honesty in communication. In this scenario, the nurse is being truthful by informing the client about the potential side effect of feeling lightheaded from transcranial magnetic stimulation and reassuring him that it should not affect his memory. This demonstrates the ethical principle of veracity as the nurse is providing accurate information to the client.
Choice A, Beneficence, is about promoting the client's well-being, which is not the focus of the nurse's action in this scenario.
Choice B, Fidelity, relates to keeping promises and being trustworthy, which is not the primary ethical principle being demonstrated.
Choice C, Autonomy, involves respecting the client's right to make decisions about their own health care, which is not explicitly demonstrated in this scenario.
Question 4 of 5
A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D: Bran cereal. This choice is appropriate for a client with GERD because bran cereal is high in fiber which helps with digestion and can reduce symptoms of GERD. Fried chicken (
A) is high in fat and can trigger GERD symptoms.
Tomato soup (
B) is acidic and can worsen GERD. Hot cocoa (
C) is also acidic and can irritate the esophagus. In summary, bran cereal is the best choice as it is low in fat and acidity, making it a suitable option for someone with GERD.
Question 5 of 5
A nurse is teaching a client who has a new prescription for levothyroxine (T4) about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?
Correct Answer: C
Rationale: The correct answer is C: Fever. Thyrotoxicosis is a condition characterized by excessive thyroid hormone levels, leading to symptoms such as increased metabolism and body temperature, which can manifest as fever. The client should monitor and report fever as it may indicate worsening of the condition. Weight gain (
A) is not typically associated with thyrotoxicosis, as it usually causes weight loss. Bradycardia (
B) is a symptom of hypothyroidism, not thyrotoxicosis. Drowsiness (
D) is also not a common symptom of thyrotoxicosis, which is more likely to cause insomnia or restlessness.