ATI CAPSTONE FUNDAMENTALS EXAM||
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A nurse is assessing a client who has Parkinson's disease. Which of the following
manifestations should the nurse expect?
Pruritus
Hypertension
Bradykinesia
Xerostomia - ANSWER: Bradykinesia;
The nurse should expect to find bradykinesia or difficulty moving in a client who
has Parkinson's disease.
A nurse is preparing to administer total parenteral nutrition (TPN) to a client.
Which of the following findings indicates a need to obtain a new bag of TPN
before administering?
The TPN solution has an oily appearance and a layer of fat on top of the solution.
The TPN solution contains added electrolytes, vitamins and trace elements.
The bag of TPN was prepared by the pharmacy 12 hours prior.
The bag of TPN is labeled with the client's name, medical record number and
prescription. - ANSWER: The TPN solution has an oily appearance and a layer of
fat on top of the solution;
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Before administration of TPN, the nurse should look for "cracking" of TPN
solution. This occurs if the calcium or phosphorous content is high or if poor-salt
albumin is added. A "cracked" TPN solution has an oily appearance or a layer of
fat on top of the solution and should not be used.
A nurse is caring for a client who is admitted for observation and has full range of
motion. Which is the best manner to encourage this client to void?
Urinal
Bedpan
Bedside Commode
Client Bathroom - ANSWER: Client Bathroom;
The goal is to encourage clients to maintain independence and privacy if the client
has full function and is able to safely complete ADLs.
A nurse is caring for a client with a stage 2 pressure ulcer. Define the
characteristics of the ulcer.
Intact skin with an area of persistent, nonblanchable redness, typically over a bony
prominence, that may feel warmer or cooler than the adjacent tissue.
Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The
ulcer may extend down to, but not through, underlying fascia.
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is
visible and superficial and may appear as an abrasion, blister, or shallow crater.
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,
bone, or supporting structures. There may be sinus tracts, deep pockets of
infection, tunneling, undermining, eschar or slough. - ANSWER: Partial-thickness
skin loss involving the epidermis and the dermis. The ulcer is visible and
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superficial and may appear as an abrasion, blister, or shallow crater. Edema
persists, and the ulcer may become infected, possibly with pain and scant drainage;
For a stage 2 pressure ulcer, the ulcer is described as partial-thickness, involving
the epidermis and dermis.
A nurse is reviewing psychosocial stages of development for a school-age child.
What would be an expected behavioral finding for this child?
Personalize values and beliefs and base reasoning on ethical fairness principles.
Establish close relationships. Have influences that help with formation of healthy
self-concept, such family and friends.
Develop sense of personal identity that family expectations influence. Peer
relationships develop as support system. Concerned with body images that media
portray.
Develop sense of industry through advances in learning. Strive to develop healthy
self- respect by finding out in what areas they excel. Peer groups play important
role in social development.
Take on new experiences and when unable to accomplish task may feel guilty or
misbehave. Generally do not exhibit stranger anxiety. Understand behavior in
terms of what is socially acceptable. - ANSWER: Develop sense of industry
through advances in learning. Strive to develop healthy self- respect by finding out
in what areas they excel. Peer groups play important role in social development;
This behavior is an expected finding of School-age children 6-12 years.
A menopausal client is having difficulty getting to sleep and asks what actions she
should incorporate in her daily routine to promote sleep. The nurse would
encourage, which of the below measures to promote sleep?