ATI RN
ATI Nur211 Capstone Questions
Question 1 of 5
A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?
Correct Answer: A
Rationale: The correct answer is A: Flexion and internal rotation of upper extremities. Decorticate posturing is characterized by the arms flexing inward towards the core of the body with internal rotation. This occurs due to damage to the corticospinal tracts. Other choices are incorrect because decerebrate posturing (extension and external rotation of upper extremities) is associated with damage to the brainstem. Extension and internal rotation (
Choice
C) and external rotation (
Choice
D) are not typical findings in decorticate posturing.
Question 2 of 5
A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?
Correct Answer: D
Rationale: The correct answer is D: Dorsiflexion of the great toe. Babinski's sign is an abnormal response where the great toe extends and the other toes fan out when the sole of the foot is stroked. In this scenario, a client with an unrepaired femur fracture suddenly becoming stuporous may indicate increased intracranial pressure. Assessing for Babinski's sign helps in detecting neurological abnormalities.
Choices A, B, and C are unrelated to Babinski's sign and are not indicative of neurological issues. Jerking contractions of the head and neck, pinpoint pupils, and pronation of the arms are not specific to Babinski's sign and do not provide relevant information in this situation.
Extract:
Medical History
Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.
Nurses' Notes
Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glascow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even, unlabored and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous members are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted.
Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.
Client's family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with last dose taken this am. Also states that the client took two aspirin yesterday for a headache.
Vital Signs
Temperature 38.5° C (101.3° F)
Pulse 110/min
Blood pressure 98/60 mm Hg Respiratory rate 26/min
Oxygen saturation 93% on 2 L nasal cannula
Diagnostic Results
RBC count 5.0 (Male 4.7 to 6.1)
WBC count 9,500 mm (5,000 to 10,000/mm3) Platelets 97,000/mm3 (150,000 to 400,000/mm3) Hemoglobin 15 g/dL (Male 14 to 18 g/dL)
Hematocrit 45% (Male 42% to 52% ; Female 37% to 47%)
Glucose 186 mg/dL (74 to 106 g/dL)
Question 3 of 5
A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.
Correct Answer: A,B,C,G,H
Rationale:
Correct
Answer: A, B, C, G
Rationale:
A: Obtaining blood cultures helps identify the causative organism for targeted antibiotic therapy.
B: Administering broad-spectrum antibiotics promptly targets potential pathogens, reducing the risk of septic shock.
C: Rapidly administering normal saline helps restore perfusion and improve hemodynamics in sepsis.
G: Measuring lactate levels aids in assessing tissue perfusion and is a key indicator of sepsis severity.
Summary of Incorrect
Choices:
D: Inserting an NG tube is not a priority in managing sepsis in the first hour.
E: Type and cross-matching for packed RBCs is not an immediate intervention for sepsis management.
F: Obtaining a urine specimen is not as crucial as the other actions in the first hour of managing sepsis.
Extract:
Question 4 of 5
A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?
Correct Answer: D
Rationale:
Correct
Answer: D -
To reduce the risk of stroke in clients who have atrial fibrillation
Rationale:
1. Dabigatran is a direct thrombin inhibitor used as an anticoagulant to prevent blood clots.
2. Atrial fibrillation increases the risk of blood clots forming in the heart, which can lead to strokes.
3. Dabigatran helps by preventing the formation of these blood clots, thus reducing the risk of stroke.
Summary:
A - Incorrect: Dabigatran does not convert atrial fibrillation to sinus rhythm. It is used for stroke prevention.
B - Incorrect: Dabigatran does not dissolve existing clots but prevents new ones from forming.
C - Incorrect: Dabigatran does not directly affect the response of the ventricles to atrial impulses. Its main purpose is stroke prevention.
Question 5 of 5
A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Speak to the client about one idea at a time. Global aphasia impairs the ability to understand and communicate effectively. By speaking about one idea at a time, the nurse helps the client focus and process information easier. This approach reduces confusion and frustration for the client.
Choice A is incorrect because multitasking can overwhelm someone with global aphasia.
Choice C is incorrect as using multiple forms of communication may be too challenging.
Choice D is incorrect as limiting questions to yes and no may not address the client's needs fully.