ATI RN
ATI Nur211 Capstone Questions
Extract:
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: The correct findings for a client with Bell's palsy include impaired taste (
A) due to involvement of the chorda tympani nerve, pain behind the ear (
B) from inflammation of the facial nerve, and muscle distortion (
C) due to facial muscle weakness. Impaired taste occurs due to the involvement of the chorda tympani nerve, which provides taste sensation to the anterior two-thirds of the tongue. Pain behind the ear arises from inflammation of the facial nerve. Muscle distortion results from weakness in the facial muscles. Facial twitching (
D) and hearing loss (E) are not typical findings in Bell's palsy.
Extract:
Progress Notes
Day 1
Client presents with abrupt onset of stroke-like manifestations with right facial droop, slurred speech, ataxia, and decrease in level of consciousness.
CT scan indicates ischemic stroke. Thrombolytic therapy with alteplase 90 mg IV over 1 hr given without incident.
Day 2
Client alert and oriented to person, place, and time; speech slightly slurred, but comprehendible. Smile asymmetrical, right side of mouth drooping. Weakness to right arm and leg. Muscle strength with unequal grips, right hand weaker, muscle strength to right leg weaker. Swallow study reports reviewed.
Day 3
Client to be discharged with prescriptions for home health including speech, physical, and occupational therapy.
Client instructed on lifestyle changes to decrease stroke risk including medication therapy for atrial fibrillation, hypertension, hyperlipidemia. Client instructed on Level 3 dysphagia diet, as well as safe practices during mealtimes. On this diet the client can eat bite-sized pieces of moist foods with near- normal textures. They should avoid very hard, sticky, or crunchy foods, such as dried fruit or nuts.
Medical History
Atrial fibrillation Hypertension Obesity Hyperlipidemia
Diagnostic Results
Day 1
CT Scan:
Non-contrast CT of client who presents with facial droop, ataxia, and decrease in level of consciousness. No evidence of acute bleeding or lesions. Slight loss of normal gray matter/white matter differentiation may indicate early ischemic changes consistent with acute infarction.
Day 2
Swallow study.
Swallow study co texture. Results it
Question 2 of 5
A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Correct Answer: B,C,E,F
Rationale:
Correct Answer: B, C, E, F
Rationale:
B: Stopping watching TV while eating promotes mindful eating, aiding in digestion.
C: Having food consistency of pudding may be required for easier swallowing post-discharge.
E: Not drinking liquids with food prevents choking risk and aids digestion.
F: Avoiding nuts can prevent choking, especially if the client has swallowing difficulties.
Summary of Incorrect
Choices:
A: Looking up at the ceiling during swallowing is incorrect as it can lead to aspiration.
D: Having cream soups may not be suitable for certain conditions and can cause swallowing issues.
G: Incomplete information provided.
Extract:
Question 3 of 5
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
Correct Answer: A
Rationale: The correct answer is A: Atrial fibrillation. Atrial fibrillation is characterized by an irregular and rapid heartbeat, which aligns with the client's symptoms of irregular palpitations and rapid heart rate with a significant pulse deficit. Atrial fibrillation can result in decreased cardiac output leading to fatigue and dizziness. Sinus bradycardia (
B) and sinus tachycardia (
C) do not match the description of a rapid and irregular heart rate with a pulse deficit. First-degree AV block (
D) is characterized by a delay in conduction between the atria and ventricles, which would not cause the rapid heart rate and pulse deficit observed in this case.
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: The correct answer is B: Increased respiratory rate. This is the earliest indicator of shock because the body initially compensates by increasing respiratory rate to improve oxygenation and perfusion. Hypotension (
A) occurs later in shock as a result of decreased cardiac output. Anuria (
C) is a late sign of shock indicating renal failure. Decreased level of consciousness (
D) occurs when brain perfusion is severely compromised.
Therefore, increased respiratory rate is the first sign of the body's attempt to compensate for decreased perfusion in shock.
Question 5 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: The correct answer is A: Heart rate 160/min. In the compensatory stage of shock, the body attempts to maintain perfusion by increasing heart rate. This is a compensatory mechanism to ensure vital organs receive adequate blood flow. A heart rate of 160/min indicates the body's attempt to maintain cardiac output.
Choices B and C are incorrect as hypokalemia and mottled skin are not specific to the compensatory stage of shock.
Choice D is incorrect because a blood pressure of 115/68 mmHg is within normal range and may not necessarily indicate compensatory shock.