ATI RN
ATI Nur211 Capstone Questions
Question 1 of 5
A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply)
Correct Answer: A,B,C
Rationale: Bell’s palsy causes impaired taste, pain behind the ear, and muscle distortion due to facial nerve involvement. Facial twitching and hearing loss are not typical.
Question 2 of 5
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Correct Answer: C
Rationale: Increased heart rate (88 to 110/min) is a compensatory sign of hypovolemic shock. Temperature rise, reduced respiratory rate, and lower urine output are less specific or later signs.
Question 3 of 5
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Tachycardia (160/min) is a compensatory mechanism in early shock. Hypokalemia and mottled skin occur later, and BP may remain normal initially.
Question 4 of 5
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Correct Answer: B
Rationale: Increased respiratory rate is an early compensatory mechanism in shock to improve oxygen delivery. Hypotension, anuria, and decreased consciousness are later signs.
Question 5 of 5
A nurse is assessing a client in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?
Correct Answer: C
Rationale: Unequal pupils with one fixed and dilated suggest increased intracranial pressure, often from ocular or head trauma. Normal variation, aging, or light exposure do not cause this.