PN ATI Capstone Proctored Comprehensive Assessment Form A

Correct Answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

Correct Answer: B

Rationale: In this scenario, the correct answer is B: Hemorrhage. Fullness in the throat post-thyroidectomy can indicate postoperative bleeding, a critical complication that requires immediate assessment and intervention. Choice A, Hypocalcemia, is incorrect because it does not typically present with fullness in the throat. Choice C, Hypoxia, is not directly related to the symptom described and is not the primary concern in this situation. Choice D, Hypothyroidism, is also incorrect as it is a long-term condition and unlikely to manifest suddenly 4 hours postoperatively with throat fullness.

Correct Answer: C

Rationale: Montelukast is a leukotriene receptor antagonist that helps reduce swelling and mucus production in the airways, making it useful for long-term asthma management.

Correct Answer: C

Rationale: The correct answer is C: 'Rice with black beans.' Plant-based proteins such as beans are recommended for clients with hepatic encephalopathy to reduce ammonia production from animal proteins. Cottage cheese (choice A), tuna salad (choice B), and a three-egg omelet (choice D) are high in animal proteins, which can contribute to increased ammonia levels in hepatic encephalopathy, making them less suitable dietary choices for these clients.

Correct Answer: B

Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.