ATI Proctored Capstone Comprehensive Assessment B 2022
1. A nurse is caring for a client who had abdominal surgery 24 hours ago.
Which of the following actions is the priority?
A. Assess fluid intake every 24 hours
B. Ambulate three times a day
C. Assist with deep breathing and coughing
D. Monitor the incision site for findings of infection:
C
The priority action the nurse should take when using the airway, breathing, circula-
tion approach to client care is to assist the client with deep breathing and coughing,
which reduces the risk for postoperative pneumonia.
2. A nurse is talking with a client who has stage IV breast cancer. The
nurse should recognize which of the following statements by the client as
a constructive use of a defense mechanism?
A. I have experienced physical discomfort when intimate with my partner
since my diagnosis
B. I wish other women would stop socializing with my partner
C. I told my doctor that I would like to start a support group for other women
who are sick in my community
D. I used to mistrust my doctor, but now I know that she is the best one to
care for me during my illness:
C
This statement indicates that the client is using the constructive defense mecha-
nism sublimation by devising a socially acceptable alternative to facing a reality
that she does not wish to accept.
3. A nurse is caring for a client who has immunosuppression and a continu-
ous IV infusion. Which of the following actions should the nurse take?
,A. Assess the clients IV site every 8 hours
B. Check the clients WBC count every 48 hours
C. Monitor the clients mouth every 8 hours
D. Change the clients IV tubing every 48 hours:
C
4. A nurse is caring for a 2-month-old infant who has Hirschsprung disease
(HD). Which of the following areas should the nurse assess for manifesta-
tions of HD?
A. Eyes area
,B. Chest area
C. Lower abdominal area:
C
Hirschsprung disease is a condition that affects the large intestine (colon) and
causes problems with passing stool. This is present at birth (congenital) as a result
of missing nerve cells in the muscle of the baby's colon
5. A nurse at a mental health clinic is caring for four clients. The nurse
should recognize that which of the following clients is using dissociation as
a defense mechanism?
A. A client forgets to buy their partner a birthday gift after a disagreement
B. A client who was abused as a child describes the abuse as if it happened
to someone else.
C. A client who is shorter than average is verbally assertive with coworkers
D. A client states that they did not get a job promotion because the boss did
not like them:
B
6. A nurse is providing teaching to a client who has a new diagnosis of type
1 diabetes mellitus. The nurse should instruct the client to monitor for which
of the following findings as a manifestation of hypoglycemia?
A. irritability
B. increased urination
C. vomiting
D. facial flushing:
A
7. A nurse in an outpatient mental health clinic is caring for four clients. The
nurse should recognize that which of the following clients is effectively using
sublimation as a defense mechanism?
, A. A client who transfers their anger about their job onto their family and then
apologizes
B. A client who misses provider appointments because they say they are too
busy
C. A client who channels their energy into a new hobby following the loss of
their job
D. A client whose partner died 4 years ago sets a place for him at dinner each
night:
C
The nurse should identify that this client is using the defense mechanism of
1. A nurse is caring for a client who had abdominal surgery 24 hours ago.
Which of the following actions is the priority?
A. Assess fluid intake every 24 hours
B. Ambulate three times a day
C. Assist with deep breathing and coughing
D. Monitor the incision site for findings of infection:
C
The priority action the nurse should take when using the airway, breathing, circula-
tion approach to client care is to assist the client with deep breathing and coughing,
which reduces the risk for postoperative pneumonia.
2. A nurse is talking with a client who has stage IV breast cancer. The
nurse should recognize which of the following statements by the client as
a constructive use of a defense mechanism?
A. I have experienced physical discomfort when intimate with my partner
since my diagnosis
B. I wish other women would stop socializing with my partner
C. I told my doctor that I would like to start a support group for other women
who are sick in my community
D. I used to mistrust my doctor, but now I know that she is the best one to
care for me during my illness:
C
This statement indicates that the client is using the constructive defense mecha-
nism sublimation by devising a socially acceptable alternative to facing a reality
that she does not wish to accept.
3. A nurse is caring for a client who has immunosuppression and a continu-
ous IV infusion. Which of the following actions should the nurse take?
,A. Assess the clients IV site every 8 hours
B. Check the clients WBC count every 48 hours
C. Monitor the clients mouth every 8 hours
D. Change the clients IV tubing every 48 hours:
C
4. A nurse is caring for a 2-month-old infant who has Hirschsprung disease
(HD). Which of the following areas should the nurse assess for manifesta-
tions of HD?
A. Eyes area
,B. Chest area
C. Lower abdominal area:
C
Hirschsprung disease is a condition that affects the large intestine (colon) and
causes problems with passing stool. This is present at birth (congenital) as a result
of missing nerve cells in the muscle of the baby's colon
5. A nurse at a mental health clinic is caring for four clients. The nurse
should recognize that which of the following clients is using dissociation as
a defense mechanism?
A. A client forgets to buy their partner a birthday gift after a disagreement
B. A client who was abused as a child describes the abuse as if it happened
to someone else.
C. A client who is shorter than average is verbally assertive with coworkers
D. A client states that they did not get a job promotion because the boss did
not like them:
B
6. A nurse is providing teaching to a client who has a new diagnosis of type
1 diabetes mellitus. The nurse should instruct the client to monitor for which
of the following findings as a manifestation of hypoglycemia?
A. irritability
B. increased urination
C. vomiting
D. facial flushing:
A
7. A nurse in an outpatient mental health clinic is caring for four clients. The
nurse should recognize that which of the following clients is effectively using
sublimation as a defense mechanism?
, A. A client who transfers their anger about their job onto their family and then
apologizes
B. A client who misses provider appointments because they say they are too
busy
C. A client who channels their energy into a new hobby following the loss of
their job
D. A client whose partner died 4 years ago sets a place for him at dinner each
night:
C
The nurse should identify that this client is using the defense mechanism of
