ATI RN
ATI Capstone Week 10 Exam Questions
Extract:
Question 1 of 5
A nurse in an oncology unit is assessing a client who has early-stage Hodgkin’s lymphoma. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Enlarged lymph nodes. In early-stage Hodgkin's lymphoma, enlarged lymph nodes are a common finding due to the abnormal growth of lymphocytes. This occurs as the cancer affects the lymphatic system. The presence of painless, firm, and rubbery lymph nodes that are fixed in place is a key characteristic. The nurse should assess for these enlarged lymph nodes in various areas of the body, such as the neck, armpits, or groin. A productive cough (
A) is not typically associated with early-stage Hodgkin's lymphoma. Bone and joint pain (
B) are more commonly seen in conditions like arthritis, not specifically in early-stage Hodgkin's lymphoma. Intermittent hematuria (
C) is not a typical finding in Hodgkin's lymphoma, as it is more indicative of urinary tract problems rather than lymphoma involvement.
Question 2 of 5
A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
Correct Answer: D
Rationale: The correct answer is D: Describe to the client the location of the food on the tray. By verbally guiding the client on the location of the food items, the nurse promotes independence in eating by enabling the client to locate and feed herself. This approach respects the client's autonomy and empowers her to make choices regarding her meal.
Explanation of other choices:
A: Asking the client if she would prefer a liquid diet does not directly promote independence in eating and may limit the client's options without her consent.
B: Assigning an assistive personnel to feed the client removes the client's autonomy and does not foster independence.
C: Placing the client's hands on the tray without explanation does not empower the client to make informed choices.
E, F, G: No additional choices provided.
Question 3 of 5
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?
Correct Answer: B
Rationale: The correct answer is B: FLACC. The FLACC scale is recommended for infants and young children who cannot verbally communicate their pain level. It assesses Face, Legs, Activity, Cry, and Consolability. This scale is particularly useful for postoperative pain assessment in infants like the 6-month-old in this scenario. The Face component looks for facial expressions indicating pain, Legs assesses the child's leg movement, Activity evaluates overall body movement, Cry measures the infant's vocalization, and Consolability checks if the infant can be comforted. The other choices are not as suitable for infants or postoperative pain assessment. Visual Analog Scale requires self-reporting, Oucher and Faces scales are more appropriate for older children who can point to a face or number to indicate pain level.
Question 4 of 5
A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?
Correct Answer: C
Rationale: The correct answer is C: Refer the client for a blood test immediately. This is appropriate because Lyme disease is diagnosed through blood tests, specifically the enzyme-linked immunosorbent assay (ELIS
A) and Western blot tests. By referring the client for a blood test immediately, the nurse can accurately assess for the presence of Lyme disease. Options A and B are incorrect as testing the tick itself is not necessary for diagnosing Lyme disease. Option D is unnecessary as the size and color of the tick do not impact the diagnosis or treatment of Lyme disease.
Question 5 of 5
A nurse in an emergency department is caring for a client who is suspected to have anaphylaxis following a bee sting. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Administer epinephrine. In anaphylaxis, prompt administration of epinephrine is crucial to reverse the severe allergic reaction and prevent further complications. Epinephrine helps to constrict blood vessels, increase heart rate, and open airways, which are essential in managing anaphylaxis. This immediate action takes priority over other interventions as it can be life-saving. Auscultating for wheezing (
A) is important but not as urgent as administering epinephrine. Assessing the client's level of consciousness (
B) can be done after administering epinephrine to stabilize the client. Monitoring for hypotension (
D) is important, but the first priority is to address the airway compromise and circulatory collapse with epinephrine.