Capstone 2989 (NUR2989) ATI Capstone quiz 7
1. A nurse is observing client care provided by assistive personnel (AP). Which of the following
actions should prompt the charge nurse to intervene?
a. The AP puts on clean gloves prior to brushing a client’s teeth.
b. The AP attaches a client’s urinary drainage bag to the bed framed
c. The AP instructs a client who needs assistance with turning to place his arms at his side
before the turn.
d. The AP applies moisturizing cream to the feet of a client who has diabetes mellitus
2. A nurse is assessing an adolescent client who has attention deficit hyperactivity disorder
(ADHD). Which of the following findings should the nurse expect?
a. Elevated mood
b. Anxiety
c. Emotional numbing
d. Impulsivity
3. A nurse is developing the plan of care for a client who does not speak the same language as
the nurse. Which of the following interventions should the nurse include?
a. Make sure a family member is present to interpret for the staff
b. Encourage the client to nod to indicates understanding
c. Determine the client’s level of fluency in his primary language
d. Speak directly to the interpreter when teaching the client
4. A nurse has completed care procedures for client who requires airborne precautions. Which
of the following items of personal protective equipment (PPE) should the nurse remove last?
a. Gloves
b. Gown
c. Mask
d. Goggle
5. Following a tornado, a nurse is determining which of the clients assigned to her care can be
discharged to free up beds for injured clients. Which of the following clients should the
nurse recommend for discharge?
a. An older adult who was admitted for diabetic ketoacidosis and his most recent ABGs show
his pH is now 7.32
b. Middle adult who is 36hr postoperative from an open laminectomy
c. An adolescent client who was admitted 24hr ago due to a spontaneous pneumothorax
d. A young adult client who has Crohn’s disease and is 1 day preoperative for an ileostomy
6. A community mental health nurse is assessing client who has schizophrenia. Which of the
following findings indicates the client might be relapsing?
a. The client reports feelings of anger toward her provider
b. The client states have started smoking again
,c. The client is wearing mismatched clothing
d. The client reports difficulties with sleeping and concentrating
7. A nurse is caring for a client whose informed consent form has been signed in preparation
for a procedure. The client states, “I have decided not to have the procedure. “Which of the
following actions should the nurse take?
a. Remind the client the consent form has already been signed
b. Discuss alternatives to the procedure
c. Explain why this procedure is necessary
d. Inform the provider that the client is withdrawing consent
8. A nurse in a mental health facility is caring for a client who is a client who is upset about the
loss of privileges due to repetitive negative behavior. Which of the following statements by
the nurse demonstrates the effective use of assertive communication?
a. “You need to calm down before discussing this matter any further”
b. “I understand that you are angry. However, I followed the appropriate protocol
c. “You were made aware of the consequences of negative behavior”
d. “Why did you make the choice to behave negatively?”
9. A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The
client’s parents are tearful and express feelings of guilt. Which of the following statements
should the nurse make?
a. “You said that you feel guilty about your daughter’s diagnosis. Lets talk about what is
causing you to feel this way”.
b. “Your provider has explained the causes of schizophrenia why you feel guilty about your
daughter diagnosis?”
c. “You should not feel guilty about your daughter’s diagnosis. Schizophrenia is unpreventable”.
d. “I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all
right once she receives the proper treatment”.
10. A nurse in the emergency department is assessing a client who has experienced intimate
partner abuse. The nurse should monitor the client for which of the following behavioral
findings?
a. Body image disturbance
b. Altered role performance
c. Personal identity disturbance
d. Self- esteem disturbance
11. A nurse is preparing to administer oral medications to a client. Which of the following
should the nurse recognize as an acceptable client identifier? (Select all that apply)
a. Partner’s full name
b. Facility room number
c. Client’s full name
d. Provider’s name
, 12. A nurse asks a client how he is feeling. The client states, “I’m feeling a bit nervous today”.
Which of the following responses should the nurse make?
a. “Would a backrub ease your nervousness?”
b. “What is making you feel nervous?”
c. “Please explain what you mean by the word nervous”
d. “You shouldn’t feel nervous”
13. A nurse is caring for a client who is experiencing a normal grief reaction following the loss
of her spouse. Which of the following finding should the nurse expect?
a. Chest pain
b. Insomnia
c. Hypertension
d. Dry month
14. A nurse is teaching a class on torts. The nurse should instruct the class that administering
an antibiotic medication to a competent client after the client has refused it is an example of
which of the following torts?
a. Negligence
b. Assault
c. Battery
d. False imprisonment
15. A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a
hospitalized client while in the cafeteria. Which of the following is the priority nursing
action?
a. Document the occurrence in a personal log
b. Complete an incident report
c. Quietly tell the APs that this is not appropriate
d. Ask the nurse manager to provide an in-service program about confidentiality to the staff on the
unit.
16. A nurse is admitting a client who requires droplet precautions due to influenza. Which of
the following actions should the nurse take?
a. Wear a mask when providing care to the client
b. Ensure the client’s room has HEPA filtration
c. Place the client in a room with negative airflow
d. Wear a gown when providing care to the client
17. A nurse sees assistive personnel (AP) entering the room of a client who requires
transmission-based precautions without using the appropriate personal protective
equipment (PPE). Which of the following actions should the nurse take first?
a. Notify the charge nurse about the AP’s need for training
b. Provide the appropriate PPE to the AP
c. Speak with AP when he exits the room about the appropriate protocol
1. A nurse is observing client care provided by assistive personnel (AP). Which of the following
actions should prompt the charge nurse to intervene?
a. The AP puts on clean gloves prior to brushing a client’s teeth.
b. The AP attaches a client’s urinary drainage bag to the bed framed
c. The AP instructs a client who needs assistance with turning to place his arms at his side
before the turn.
d. The AP applies moisturizing cream to the feet of a client who has diabetes mellitus
2. A nurse is assessing an adolescent client who has attention deficit hyperactivity disorder
(ADHD). Which of the following findings should the nurse expect?
a. Elevated mood
b. Anxiety
c. Emotional numbing
d. Impulsivity
3. A nurse is developing the plan of care for a client who does not speak the same language as
the nurse. Which of the following interventions should the nurse include?
a. Make sure a family member is present to interpret for the staff
b. Encourage the client to nod to indicates understanding
c. Determine the client’s level of fluency in his primary language
d. Speak directly to the interpreter when teaching the client
4. A nurse has completed care procedures for client who requires airborne precautions. Which
of the following items of personal protective equipment (PPE) should the nurse remove last?
a. Gloves
b. Gown
c. Mask
d. Goggle
5. Following a tornado, a nurse is determining which of the clients assigned to her care can be
discharged to free up beds for injured clients. Which of the following clients should the
nurse recommend for discharge?
a. An older adult who was admitted for diabetic ketoacidosis and his most recent ABGs show
his pH is now 7.32
b. Middle adult who is 36hr postoperative from an open laminectomy
c. An adolescent client who was admitted 24hr ago due to a spontaneous pneumothorax
d. A young adult client who has Crohn’s disease and is 1 day preoperative for an ileostomy
6. A community mental health nurse is assessing client who has schizophrenia. Which of the
following findings indicates the client might be relapsing?
a. The client reports feelings of anger toward her provider
b. The client states have started smoking again
,c. The client is wearing mismatched clothing
d. The client reports difficulties with sleeping and concentrating
7. A nurse is caring for a client whose informed consent form has been signed in preparation
for a procedure. The client states, “I have decided not to have the procedure. “Which of the
following actions should the nurse take?
a. Remind the client the consent form has already been signed
b. Discuss alternatives to the procedure
c. Explain why this procedure is necessary
d. Inform the provider that the client is withdrawing consent
8. A nurse in a mental health facility is caring for a client who is a client who is upset about the
loss of privileges due to repetitive negative behavior. Which of the following statements by
the nurse demonstrates the effective use of assertive communication?
a. “You need to calm down before discussing this matter any further”
b. “I understand that you are angry. However, I followed the appropriate protocol
c. “You were made aware of the consequences of negative behavior”
d. “Why did you make the choice to behave negatively?”
9. A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The
client’s parents are tearful and express feelings of guilt. Which of the following statements
should the nurse make?
a. “You said that you feel guilty about your daughter’s diagnosis. Lets talk about what is
causing you to feel this way”.
b. “Your provider has explained the causes of schizophrenia why you feel guilty about your
daughter diagnosis?”
c. “You should not feel guilty about your daughter’s diagnosis. Schizophrenia is unpreventable”.
d. “I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all
right once she receives the proper treatment”.
10. A nurse in the emergency department is assessing a client who has experienced intimate
partner abuse. The nurse should monitor the client for which of the following behavioral
findings?
a. Body image disturbance
b. Altered role performance
c. Personal identity disturbance
d. Self- esteem disturbance
11. A nurse is preparing to administer oral medications to a client. Which of the following
should the nurse recognize as an acceptable client identifier? (Select all that apply)
a. Partner’s full name
b. Facility room number
c. Client’s full name
d. Provider’s name
, 12. A nurse asks a client how he is feeling. The client states, “I’m feeling a bit nervous today”.
Which of the following responses should the nurse make?
a. “Would a backrub ease your nervousness?”
b. “What is making you feel nervous?”
c. “Please explain what you mean by the word nervous”
d. “You shouldn’t feel nervous”
13. A nurse is caring for a client who is experiencing a normal grief reaction following the loss
of her spouse. Which of the following finding should the nurse expect?
a. Chest pain
b. Insomnia
c. Hypertension
d. Dry month
14. A nurse is teaching a class on torts. The nurse should instruct the class that administering
an antibiotic medication to a competent client after the client has refused it is an example of
which of the following torts?
a. Negligence
b. Assault
c. Battery
d. False imprisonment
15. A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a
hospitalized client while in the cafeteria. Which of the following is the priority nursing
action?
a. Document the occurrence in a personal log
b. Complete an incident report
c. Quietly tell the APs that this is not appropriate
d. Ask the nurse manager to provide an in-service program about confidentiality to the staff on the
unit.
16. A nurse is admitting a client who requires droplet precautions due to influenza. Which of
the following actions should the nurse take?
a. Wear a mask when providing care to the client
b. Ensure the client’s room has HEPA filtration
c. Place the client in a room with negative airflow
d. Wear a gown when providing care to the client
17. A nurse sees assistive personnel (AP) entering the room of a client who requires
transmission-based precautions without using the appropriate personal protective
equipment (PPE). Which of the following actions should the nurse take first?
a. Notify the charge nurse about the AP’s need for training
b. Provide the appropriate PPE to the AP
c. Speak with AP when he exits the room about the appropriate protocol
