ATI RN Capstone Ment al Health Pr e-Assessment ,
ATI Capstone Pr octored Compr ehensiv e
Assessment Form A
Terms in this set (73)
Antibiotics Affecting Pr otein
Synthesis: Pr oviding Client
Educa tion About
Tetracycline- Take with meal s if GI distress occur s
- Take on empty stomach with 8 oz of water
- Avoid taking at bedtime
- Do not take it before lying down
- Compl ete entir e course
- Util ize additional contr aceptiv es
- Wear protectiv e clothing and use sunscr een with an
SPF of 30 or higher while outdoor s
- Notify provider of diarrhea or yeast infection
- Ensur e that any milk products and antacids are
separated by 2 hour s
Associa ted manif estation of
Hyperk alemiaECG with tall, peak ed t-waves
Associa ted manif estation of
Hypocal cemiaPositiv e Trousseau' s sign
Associa ted manif estation of
Hypok alemiaHypo active bowel sounds
Associa ted manif estation of
Hypona tremiaBounding pul se A charge nur se is
conducting a staff
educa tion in-ser vice about
depr essiv e disor ders. Which
of the following shoul d the
nurse identify as a risk
factor for depr ession?
a. Being married.
b. Pregnancy .
c. Mal e gender .
d. Chronic il lness.d. Chronic il lness
Having a medical illness, especial ly one that is chronic, is
a primar y risk factor for depr ession.
Ches t Tube Insertion and
Monit oring: Caring for a
Client Who Has a Ches t
TubePostprocedur e:
- Assess VS, breath sounds, SaO2, color, and r espir atory
effort at least every 4 hour s
- Encour age coughing and deep breathing e very 2 hour s
- Keep drainage system bel ow the clients ches t level
- Check water seal every 2 hour s
- Document the amount and color of drainage hourl y for
the first 24 hour s and e very 8 hrs afterwards.
- Report excessiv e drainage (> 70 mL/hr )
- Monit or ches t tube insertion sit e for redness, p ain,
infection , and crepitus
- Position client semi or high F owler's position
- Keep two encl osed hemos tats, sterile water and an
occlusive dressing at bedside at all times
- Ches t tubes are clamps in case of air leak, during
drainage system change, accident al disconnection of
tubing or dama ge.
Ches t TubesChes t tubes are insert ed int o the pl eural space to drain
fluid, bl ood, or air; reestablish a nega tive pressur e;
facilitate lung e xpansion; and r estore intr apleural
pressur e. Ches t Tube SystemsA disposabl e three - chamber drainage system is mos t
often used
- First chamber : drainage collection
- Second chamber : Water seal
- Third chamber : Suction contr ol (can be wet or dry)
A client who has bipol ar
disor der appr oaches the
nurse and r eveals fresh,
self-inflicted, superficial
cuts going up and down his
right arm. Which of the
following actions shoul d the
nurse take first?
a. Impl ement the client's
beha vioral modifica tion
plan.
b. Document the siz e and
location of the cuts.
c. Inspect the cuts for
debris.
d. Adminis ter a tetanus
antitoxin.c. Inspect the cuts for debris.
The first action the nur se shoul d take when using the
nursing pr ocess is to assess the client, therefore
inspecting the cuts is the first action the nur se shoul d
take.
Continuous bubbl ing in the
water seal chamber
indica tes...Air leak in the s ystem.
DM: Mixing Insul ins in the
Same SyringeWhen mixing short -acting insul in with l onger -acting
insulin:
1. Draw the short -acting insul in up into the s yringe first
2. Dr aw the longer -acting insul in ne xt
Dyspha gia diet Prescribed when s wallowing is impaired. Electrolyte Imb alances:
Identifying Manif estations
of a Calcium Imb alanceHypocal cemia:
- Level: <9 mg/dL
- Risk factors: Calcium deficit, diarrhea , end-s tage kidney
disease, wound drainage; alkalosis, acute pancreatitis,
immobil ity, parathyroid removal/dama ge
- S&S: Tetany (mos t common manif estation), paresthesia
of the finger s and l ips, muscl e twitches,
seizur e, muscl e spasms, hyper active DTRs, positiv e
Chvostek's sign ( facial twitching) , positiv e Trousseau' s
sign (hand/ finger spasms with BP cuff inflation),
cardiovascul ar irregularities, diarrhea , abdominal cramps
- Tx: Vitamin D suppl ements
- Compl ications: Cardiac arrest
Gastrointestinal Disor ders:
Teaching About
Scopol amineClient educa tion:
- Can cause seda tion
- Avoid activities that requir e alertness
- Incr ease fluid int ake
- Incr ease phy sical activity by enga ging in r egular
exercise
- Suck on har d candy or chew gum to help relieve dry
mouth
- Void e very 4 hour s
Infection Control: Infectious
Diseases to Report60 communicabl e diseases that mus t be report ed to the
public heal th departments
- TB
- Hep atitis A
Intermedia te-acting Insul inPeak: 4-14 hour s
NPH insul in
It is common to see
bubbl ing during...- exhalation
- snee zing
- coughing
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