PN ATI CAPSTONE PROCTORED COMPREHENSIVE
ASSESSMENT FORM A
Answer
hopelessness.
Explanation
The key concept here involves identifying signs of potential suicidal ideation in a client based on their
reported feelings and behaviors. The client's expressions of hopelessness, withdrawal, and depression
are critical indicators that suggest they may be at risk for self-harm or suicidal thoughts.
The correct completion of the sentence would be "hopelessness." This is supported by the client's
statement about feeling depressed and describing their life as a mess, which reflects a lack of hope for
the future.
Here are further explanations.
• Option A: While emotional instability can be a factor in mental health, it does not directly
indicate suicidal ideation as clearly as hopelessness does.
• Option B: Hypervigilance is more related to anxiety and stress responses rather than a direct
sign of suicidal thoughts.
• Option C: Although withdrawal from family and friends can be a concerning behavior, it is the
expression of hopelessness that most directly correlates with suicidal ideation.
,Question 84:
A nurse is assisting with the care of a client on a medical-surgical unit. Which of the following actions
should the nurse take as part of the isolation precautions for this client? Select all that apply.
Vital Signs:
• Temperature: 38.9°C (102°F)
• Heart rate: 100/min
• Respiratory rate: 24/min
Answer Options:
• A: Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's
room.
• B: When removing personal protective equipment, remove gloves first.
• C: Provide a mask for the client when they are outside their room.
• D: Place the client in a room with positive air flow.
• E: Don a gown when entering the client's room.
Correct Answers:
, • A: Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's
room.
• B: When removing personal protective equipment, remove gloves first.
• C: Provide a mask for the client when they are outside their room.
• E: Don a gown when entering the client's room.
Explanation:
In this case, the client appears to have an infection, as indicated by the elevated temperature (38.9°C)
and elevated heart rate. The nurse should follow proper isolation protocols to prevent the spread of
infection. Here’s why the correct actions are listed:
• A: Hand hygiene is crucial to prevent cross-contamination. The nurse should use at least 4 to 5
mL of hand sanitizer after leaving the patient's room to eliminate any pathogens.
• B: Proper protocol for removing personal protective equipment (PPE) is to remove gloves first,
as they are the most contaminated item.
• C: If the client needs to leave the room (e.g., for transport), a mask should be provided to
prevent the spread of potential airborne pathogens.
• E: Gowns should be worn when entering a patient’s room to protect from bodily fluids or
contamination from the environment.
D: Place the client in a room with positive airflow is not correct in this case unless the patient has a
condition that requires airborne isolation, like tuberculosis. In this scenario, positive airflow would not
be the standard requirement.
, Question 83:
A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes
simplex virus with active lesions. Which of the following actions should the nurse take?
Answer:
• A: Initiate an oxytocin infusion for the client.
Explanation:
In this scenario, the nurse must focus on preventing the transmission of herpes simplex virus (HSV) to
the newborn during delivery. The presence of active lesions at the time of delivery typically indicates the
need for a C-section to avoid exposure to the virus. Although oxytocin is used to stimulate labor, the
priority in this case is to ensure that the mother undergoes a caesarean section (C-section), which is the
recommended mode of delivery when the mother has active herpes lesions. Vaginal delivery could
expose the newborn to the virus, leading to serious complications such as neonatal herpes.
ASSESSMENT FORM A
Answer
hopelessness.
Explanation
The key concept here involves identifying signs of potential suicidal ideation in a client based on their
reported feelings and behaviors. The client's expressions of hopelessness, withdrawal, and depression
are critical indicators that suggest they may be at risk for self-harm or suicidal thoughts.
The correct completion of the sentence would be "hopelessness." This is supported by the client's
statement about feeling depressed and describing their life as a mess, which reflects a lack of hope for
the future.
Here are further explanations.
• Option A: While emotional instability can be a factor in mental health, it does not directly
indicate suicidal ideation as clearly as hopelessness does.
• Option B: Hypervigilance is more related to anxiety and stress responses rather than a direct
sign of suicidal thoughts.
• Option C: Although withdrawal from family and friends can be a concerning behavior, it is the
expression of hopelessness that most directly correlates with suicidal ideation.
,Question 84:
A nurse is assisting with the care of a client on a medical-surgical unit. Which of the following actions
should the nurse take as part of the isolation precautions for this client? Select all that apply.
Vital Signs:
• Temperature: 38.9°C (102°F)
• Heart rate: 100/min
• Respiratory rate: 24/min
Answer Options:
• A: Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's
room.
• B: When removing personal protective equipment, remove gloves first.
• C: Provide a mask for the client when they are outside their room.
• D: Place the client in a room with positive air flow.
• E: Don a gown when entering the client's room.
Correct Answers:
, • A: Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's
room.
• B: When removing personal protective equipment, remove gloves first.
• C: Provide a mask for the client when they are outside their room.
• E: Don a gown when entering the client's room.
Explanation:
In this case, the client appears to have an infection, as indicated by the elevated temperature (38.9°C)
and elevated heart rate. The nurse should follow proper isolation protocols to prevent the spread of
infection. Here’s why the correct actions are listed:
• A: Hand hygiene is crucial to prevent cross-contamination. The nurse should use at least 4 to 5
mL of hand sanitizer after leaving the patient's room to eliminate any pathogens.
• B: Proper protocol for removing personal protective equipment (PPE) is to remove gloves first,
as they are the most contaminated item.
• C: If the client needs to leave the room (e.g., for transport), a mask should be provided to
prevent the spread of potential airborne pathogens.
• E: Gowns should be worn when entering a patient’s room to protect from bodily fluids or
contamination from the environment.
D: Place the client in a room with positive airflow is not correct in this case unless the patient has a
condition that requires airborne isolation, like tuberculosis. In this scenario, positive airflow would not
be the standard requirement.
, Question 83:
A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes
simplex virus with active lesions. Which of the following actions should the nurse take?
Answer:
• A: Initiate an oxytocin infusion for the client.
Explanation:
In this scenario, the nurse must focus on preventing the transmission of herpes simplex virus (HSV) to
the newborn during delivery. The presence of active lesions at the time of delivery typically indicates the
need for a C-section to avoid exposure to the virus. Although oxytocin is used to stimulate labor, the
priority in this case is to ensure that the mother undergoes a caesarean section (C-section), which is the
recommended mode of delivery when the mother has active herpes lesions. Vaginal delivery could
expose the newborn to the virus, leading to serious complications such as neonatal herpes.
