ATI Capstone Comprehensive Assessment A
1. 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
2. Caring for a Client Who Has Immunosuppression: monitor skin and
mucous membranes for infection (breakdown, fissures, and abscess)
3. 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
4. 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
, ATI Capstone Comprehensive Assessment A
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)
5. 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
6. managing adverse effects of risperidone: orthostatic hypotension
-nursing actions: monitor blood pressure and heart rate for orthostatic changes
-client education: change position slowly
7. 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
8. preparing for a sterile dressing change: do not turn your back on a sterile
field
9. 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
1. 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
2. Caring for a Client Who Has Immunosuppression: monitor skin and
mucous membranes for infection (breakdown, fissures, and abscess)
3. 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
4. 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
, ATI Capstone Comprehensive Assessment A
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)
5. 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
6. managing adverse effects of risperidone: orthostatic hypotension
-nursing actions: monitor blood pressure and heart rate for orthostatic changes
-client education: change position slowly
7. 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
8. preparing for a sterile dressing change: do not turn your back on a sterile
field
9. 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
