ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse cares for a client who is experiencing status epilepticus. Which medication would the nurse prepare for administration?
Correct Answer: A
Rationale: The correct answer is A: Lorazepam. In status epilepticus, immediate treatment is crucial to stop ongoing seizures. Lorazepam is a fast-acting benzodiazepine that helps terminate seizures quickly. It acts by enhancing the effect of GABA, an inhibitory neurotransmitter, leading to sedation and seizure control. Atenolol (
B) is a beta-blocker used for hypertension, not seizures. Phenytoin (
C) and Levetiracetam (
D) are antiepileptic drugs used for long-term seizure management but are not ideal for acute seizure control like in status epilepticus.
Question 2 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 3 of 5
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?
Correct Answer: A
Rationale: The correct answer is A: Ability to self-feed with the use of adaptive equipment. This goal is appropriate because a client with a spinal cord transection at the level of C5 typically has impaired hand function but retains some shoulder and elbow movement. Self-feeding is a basic activity of daily living that can enhance the client's independence and quality of life. Options B and C require higher levels of upper extremity function, which are usually impaired in a client with a C5 spinal cord injury. Option D involves autonomic nervous system functions that are controlled by segments below the level of the injury and are not typically affected by a C5 transection.
Question 4 of 5
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Hypovolemia. A low CVP in a client with multiple traumas indicates decreased blood volume, leading to hypovolemia. This can be due to blood loss from trauma. Other choices are incorrect: A (Fluid overload) would result in elevated CVP, C (Left ventricular failure) would typically show an elevated CVP, and D (Intracardiac shunt) would not directly affect CVP. It is crucial for the nurse to recognize hypovolemia promptly in trauma patients to initiate appropriate interventions.
Question 5 of 5
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?
Correct Answer: D
Rationale: The correct answer is D: The P wave falls before the QRS complex. In a normal sinus rhythm, the P wave should precede the QRS complex, indicating that the electrical impulse originates in the sinoatrial (S
A) node and travels through the atria before reaching the ventricles. This sequence signifies a coordinated electrical conduction through the heart, ensuring efficient and effective pumping.
Choices A, B, and C are incorrect as they describe abnormalities in the ECG readings that are not indicative of normal sinus rhythm.
Choice A suggests a prolonged PR interval, choice B indicates T wave inversion which can be a sign of cardiac ischemia or electrolyte imbalance, and choice C implies a widened QRS complex which may indicate conduction abnormalities.
Therefore, the correct interpretation of a normal sinus rhythm on ECG is when the P wave falls before the QRS complex.