ATI Capstone Comprehensive Assessment A 100% VERIFIED ANSWERS 2024/2025 CORRECT STUDY S, Exams of Nursing

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ATI Capstone Comprehensive

Assessment A 100% VERIFIED

ANSWERS 2024/

CORRECT STUDY SET

Assessing the Care Environment for a Client Who is Experiencing Suicidal Ideations

• search the client's belonging with the client present. Remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal nail files, tweezers, matches, razors, perfume, shampoo, plastic bags, and other potentially harmful items from the client's room and vicinity
• allow the client to use only plastic eating utensils. Count utensils when brought into and out of the client's room
• check the environment for possible hazards (windows that open, overhead pipes that are easily accessible, non-breakaway shower rods, non-recessed shower nozzles)
• ensure that the client's hands are always visible, even when sleeping Caring for a Client Who Has Immunosuppression monitor skin and mucous membranes for infection (breakdown, fissures, and abscess) Developing an Emergency Preparedness Plan The Hospital Incident Command System (HICS) for disaster management offers a clear structure for disaster management at the facility level Identifying Reportable Diseases
• Nurses are also mandated to report to the proper agency (local health department, state health department) when a client is diagnosed with a communicable disease
• a complete list of reportable diseases and a description of the reporting system are available through the Centers for Disease Control and Prevent Web site. Each state mandates which diseases must be reported in that state. There are more than 60 communicable diseases that must be

reported to public health departments to allow officials to do the following: ensure appropriate medical treatment of diseases (tuberculosis), monitor for common-source outbreaks (foodborne: hepatitis A), plan and evaluate control and prevention plans (immunizations for preventable diseases), identify outbreaks and epidemics, determine public health priorities based on trends, educate the community on prevention and treatment of these diseases Nationally notifiable diseases: identified at the CDC website and include the following

• anthrax, botulism, cholera, congenital rubella syndrome (CRS), diphtheria, giardiasis, gonorrhea, hepatitis A, B, C, HIV, influenza-associated pediatric mortality, legionellosis/legionnaires' disease, lyme disease, malaria, meningococcal disease, mumps, pertussis (whooping cough), poliomyelitis, paralytic, poliovirus infection, nonparalytic, rabies (human or animal), rubella (german measles), salmonellosis, severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV), shigellosis, smallpox, syphilis, tetanus/C. tetani, toxic shock syndrome (TSS) (other than streptococcal), tuberculosis (TB), typhoid fever, vancomycin-intermediate and vancomycin-resistant, viral hemorrhagic fever, staphylococcus aureus (VISA/VRSA) Identifying a Prescription to Clarify With the Provider
• caused by damage to sensory nerve fibers resulting in numbness and pain **peripheral neuropathy includes focal neuropathies, caused by acute ischemic damage or diffuse neuropathies, which are more widespread and involve slow, progressive loss. This can lead to complications (foot deformities, ulcers). **autonomic neuropathy can affect nerve conduction of the heart (exercise intolerance, painless myocardial infarction, altered left ventricular function, syncope), gastrointestinal system (gastroparesis, reflux, early satiety), and urinary tract (decreased bladder sensation, urinary retention). It affects the autonomic nervous system, which minimizes manifestations of hypoglycemia (diaphoresis, tremors, palpitations), which can be dangerous for the client
• clients who have impaired sensory perception might not feel numbness, pain, or burning managing adverse effects of risperidone orthostatic hypotension
• nursing actions: monitor blood pressure and heart rate for orthostatic changes
• client education: change position slowly placing a client in side-lying position

• position clients, especially those who are unable to move themselves, so that they maintain good body alignment. Frequent position changes prevent discomfort, contractures, pressure on tissues, and nerve and circulatory damage, and they stimulate postural reflexes and muscle tone
• use pillows, bath blankets, hand rolls, boots, splints, trochanter rolls, ankle support devices, and other aids to maintain proper body alignment preparing for a sterile dressing change do not turn your back on a sterile field teaching care seat safety motor vehicle injury
• place infants and toddlers in a rear-facing car seat until 2 years of age or until they exceed the height and weight limit of the car seat. They can then sit in a forward-facing car seat
• use a car seat with a five-point harness for infants and children
• all car seats should be federally approved and be placed in the back seat, which is the safest place in the vehicle
• infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height recommended by manufacturer
• toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing car seats, should use a forward-facing car seat until they reach the height and weight requirements for a booster seat
• newborn infants should be placed in a federally approved car seat at a 45 degree angle to prevent slumping and airway obstruction. The car seat is placed rear facing in the rear seat of the vehicle and secured using the safety belt. The shoulder harnesses are placed in the slots at or below the level of the infant's shoulders. The harness should be snug and the retainer clip placed at the level of the intant's armpits Educating staff nurses about organ donation
• recognize that requests for tissue and organ donations must be made by specifically trained personnel
• provide support and education to family members as decisions are being made. Use private areas for any family discussions concerning donation

• be sensitive to cultural and religious influences
• maintain ventilatory and cardiovascular support for vital organ retrieval evaluating staff performance
• have one or more staff members assist with positioning clients. moving them up in bed is a significant cause of back pain and injury
• keep your head and neck in a straight line with your pelvis to avoid neck flexion and hunched shoulders, which can cause impingement of nerves in your neck
• use smooth movements when lifting and moving clients to prevent injury from sudden or jerky muscle movements
• when standing for long periods of time, flex your hips and knees by using a footrest. when sitting for long periods of time, keep your knees slightly higher than your hips
• avoid repetitive movements of the hands, wrists, and shoulders. take a break every 15 to 20 min to flex and stretch joints and muscles whenever possible
• avoid twisting your spine or bending at the waist (flexion) to minimize the risk for injury evaluating the need for a chest compression vest high-frequency chest compression uses a mechanical chest device combined with nebulization therapy identifying resources to improve health care for migrant farmworkers agency for healthcare research and quality (AHRQ): conducts research to improve the quality, affordability, and safety of healthcare services. uses research data to publish clinical guidelines and recommendations for a variety of health conditions information to include in a change of shift report nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients
• formats include face-to-face, audiotaping, or presentation during walking rounds in each client's room (unless the client has a roommate or visitors are present)
• an effective report should: include significant objective information about the client's health problems, proceed in a logical sequence, include no gossip or personal opinion, relate recent changes in medications, treatment, procedures, and the discharge plan

hand-off or change-of-shift report

• performed with the nurse who is assuming responsibility for the client's care
• describes the current health status of the client
• informs the next shift of pertinent client care information
• provides the oncoming nurse the opportunity to ask questions and clarify the plan of care
• should be given in a private area (a conference room or at the bedside) to protect client confidentiality priority steps in the time management process time initially spent developing a plan will save time later and help to avoid management by crisis client teaching about basal body temperature method of contraception BBT is the temperature of the body at rest. prior to ovulation, the temperature drops slightly and rises during ovulation. identifying the time of ovulation is a symptom-based method that can be used to facilitate or avoid conception evaluating guardians' understanding of child safety measures avoid sun exposure between 1000 and 1400, wear protective clothing, and apply sunscreen to prevent sunburn sequence of performing an abdominal assessment for most body systems, follow the sequence of first inspecting, then palpating, followed by percussion, and finally auscultation the exception is the abdomen; inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds expected findings of autism spectrum disorder
• delays in at least one of the following: social interaction, social communication, imaginative play prior to age 3 years
• distress when routines are changed
• unusual attachments to objects
• inability to start or continue conversation
• using gestures instead of words

• delayed or absent language development
• grunting or humming
• inability to adjust gaze too look at something else
• not referring to self correctly
• withdrawn, labile mood
• lack of empathy
• decreased pain sensation
• spending time along rather than playing with others
• avoiding eye contact
• withdrawal from physical contact
• heightened or lowered senses
• not imitating actions of others
• minimal pretend play
• short attention span
• intense temper tantrums
• showing aggression
• exhibiting repetitive movements
• typical IQ less than 70 dietary modification for a client who has crohn's disease educate the client to eat high-protein, high-calorie, low-fiber foods planning care for a client who has rheumatoid arthritis encourage foods high in vitamins, protein, and iron evaluating the effectiveness of chlorpromazine
• treatment of acute and chronic psychotic disorders
• schizophrenia spectrum disorders
• bipolar disorder: primarily the manic phase
• tourette disorder
• agitation
• prevention of nausea/vomiting through blocking of dopamine in the chemoreceptor trigger zone of the medulla

intervention for lorazepam overdose

• administer flumazenil for benzodiazepine toxicity to counteract sedation and reverse adverse effects
• IV: administer flumazenil to counteract sedation and reverse adverse effects priority action for insulin administration measure doses accurately, and double-check dosages of high-alert medications (insulin and heparin) with a colleague. check the medication's expiration date teaching about estradiol estrogen either suppresses blood coagulation or promotes it; the effect depends on genetic influences. monitor for embolic event (MI, pulmonary embolism, DVT, stroke) teaching about manifestations of digoxin toxicity monitor for indications of anorexia, nausea, vomiting, visual disturbances, dysrhythmias vitamin k administration following birth administered to prevent hemorrhagic disorders. vitamin K is not produced in the gastrointestinal tract of the newborn until around day 7. vitamin K is produced in the colon by bacteria once formula or breast milk is introduced expected laboratory values in a toddler who has hemophilia A prolonged partial thromboplastin time (aPTT) laboratory values to report to the provider following hemodialysis excessive sodium retention: kidney failure, Cushing's syndrome, aldosteronism, some medications (glucocorticosteroids) manifestations of multiple sclerosis nystagmus manifestations of vaso-occlusive crisis hematuria

reportable findings for a newborn normal temperature range is 36.5C to 37.5C (97.7F to 99.5F), with 37C (98.6) being average. the newborn is at risk for hypothermia and hyperthermia until thermoregulation (ability to produce heat and maintain normal body temperature) stabilizes. if the newborn becomes chilled (cold stress), oxygen demands can increase and acidosis can occur assessing oxygen toxicity nonproductive cough, substernal pain, nausea, vomiting, fatigue, dyspnea, restlessness, paresthesias creating plan of care for a child antibiotics

• administer through IV or aerosol
• specific to treat the pulmonary infection. common medications include tobramycin, ticarcillin, or gentamicin
• nursing actions: assess for allergies, high doses may be prescribed. collect blood specimens before and after some IV antibiotics to maintain therapeutic levels expected findings of the acute phase of kawasaki disease onset of high fever, lasting 5 days to 2 weeks, that is unresponsive to antipyretics
• irritability, red eyes without drainage, bright red, chapped lips, strawberry tongue with white coating or red bumps on the posterior aspect, red oral mucous membranes with inflammation including the pharynx, swelling of hand and feet with red palms and soles, nonblistering rash, bilateral joint pain, enlarged lymph nodes, desquamation of the perineum, cervical lymphadenopathy, cardiac manifestations: myocarditis, decreased left ventricular function, pericardial effusion, and mitral regurgitation home wound care teaching
• in most instances, the surgeon will perform the first dressing change. subsequent dressing changes can be performed by the nurse using surgical aseptic technique
• preventing infection by using aseptic technique when performing dressing changes identifying visual changes due to cataracts opacity in the lens of an eye that impairs vision

period of communicability for varicella 1 to 2 days before lesions appear until all lesions have formed crusts priority action to promote ambulation noted pain experts agree that pain is whatever the person experiencing it says it is, and it exists whenever the person says it does. the client's report of pain is the most reliable diagnostic measure of pain teaching about manifestations of ovarian cancer abdominal pain or swelling/abdominal discomfort actions for a client who is experiencing excessive postpartum bleeding

• assess bladder for distention. insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output
• caring attitude: show concern and facilitate an emotional connection and support among nurses and clients, families, and significant others
• firmly massage the uterine fundus
• perineal pad saturation in 15 min or less
• constant oozing, trickling, or frank flow of bright red blood from vagina
• provide oxygen at 10 to 12 L/min via nonrebreather facemask, and monitor oxygen saturation therapeutic intent: controls postpartum hemorrhage actions to take for a preschooler experiencing an anaphylactic reaction
• cardiovascular manifestations include weak, thready pulse, tachycardia, and hypotension
• hypotension is a blood pressure below the expected reference range (systolic less than 90 mm Hg) and can be a result of fluid depletion, heart failure, or vasodilation
• if indications of allergy appear (urticaria, rash, hypotension, dyspnea), stop the cephalosporin immediately, and notify the provider
• monitor hemodynamic status. the client usually experiences extensive vasodilation and capillary leak (tachycardia, weak pulse)
• Provide rapid intervention including epinephrine ddministration for severe allergic reaction to prevent death. notify the rapid response team of anaphylaxis is suspected actions to take to maintain client safety

• assess client's suicide plan
• ensure client swallow all medications
• initiate one-on-one constant supervision
• search client's belongings with the client present anticipating provider prescriptions for postoperative complications
• compression. of nerves, blood vessels, and muscle inside a confined place, resulting in neuromuscular ischemia; most commonly occurring in relation to tibial fractures or fractures involving the forearm
• loosen the dressing or open and bivalve the cast
• prepare the client for fasciotomy assessing risk for a client who is postpartum and has preeclampsia
• increased plasma uric acid
• seizures
• preeclampsia is GH with the addition of proteinuria of greater than or equal to 1+. report of transient headaches might occur along with episodes of irritability. edema can be present assessment and management of postoperative complications
• administer IV fluid and electrolyte replacement
• dehydration
• high-pitched bowel sounds above site of obstruction
• place in semi-fowler's position caring for a client who has schizophrenia
• hyperactivity such as pacing, restlessness
• low risk of EPS
• tardive dyskinesia (TD): manifestations include involuntary movements of the tongue and face, such as lip-smacking which cause speech and/or eating disturbances, can also include involuntary movements of arms, legs, or trunk caring for a client who has a psychobiological disorder Nursing care
• accept somatic manifestations as being real to the client

• assess for suicidal ideation and thoughts of self-harm
• identify the cultural impacts of the client's view of health and illness
• identify secondary gains from somatic manifestations attention distraction from personal obligations or problems
• report new physical manifestations to the provider
• limit the amount of time allowed to discuss somatic manifestations
• encourage independence and self care
• encourage verbalization of feelings
• educate the client on alternative coping mechanisms
• educate the client on assertiveness techniques
• encourage daily physical exercise Patient Health questionnaire 15 (PHQ-15): Used to identify the presence of the 15 most commonly reported somatic manifestations
• Abdominal pain, back pain, pain in the extremities/joints, menstrual problems or cramps, headaches, chest pain, dizziness, fainting, heart pounding or racing, dyspnea, problems or pain with sexual intercourse, problems with bowel elimination (constipation/diarrhea), nausea, indigestion or gas, lethargy, problem sleeping somatic symptom disorder: somatization is the expression of psychological stress through physical manifestations evaluating outcomes for an adolescent who is postoperative
• capillary refill
• increased ain unrelieved with elevation or by pain medication, or elevation
• paresthesia or numbness (early finding)
• pulselessness distal to the fracture (late finding)
• skin temperature identifying complications during transfusion of packed red blood cells chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom identifying complications of bulimia nervosa

• cardiac dysrhythmias, severe bradycardia, and hypotension
• hyponatremia identifying findings of attention deficit hyperactivity disorder and intellectual disability
• blurting out responses before questions are asked
• decreased response to social cues
• decreasing stimuli in the environment
• evidence of social or academic impairment
• inattention
• language difficulties identifying manifestations of inflammatory bowel diseases
• abdominal pain/cramping: often right-lower quadrant pain
• albumin: decreased
• anorexia and weight loss
• crohn's disease
• diarrhea: five loose stools/day with mucous or pus
• fever
• tachycardia
• WBC: increased identifying risks for a child who has a gastrostomy tube 2 to 11 days after injury or surgery
• purulent drainage, pain, redness, edema (in and around the wound), fever, chills, odor, increased pulse respiratory rate, increase in WBC count skin irritation around the tubing site
• provide a skin barrier for any drainage at the site, monitor the tube's placement nursing actions to promote venous circulation
• client often report muscle cramping and aches, pain after sitting, and pruritus
• elastic (antiembolic) stockings cause external pressure on the muscles of the lower extremities to promote blood return to the heart
• varicose veins are enlarged, twisted, and superficial veins that can occur in any part of the body;

however, they are commonly observed in the lower extremities and in the esophagus

• when suspecting poor venous return or possible thrombus, notify the provider, elevate the leg, and do not apply pressure or massage the thrombus to avoid dislodging it