ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 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 2 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:
Nurses' Notes
Day 1:
Client admitted to the medical-surgical unit from the emergency department (ED). Client came to the ED after sudden onset of dizziness, numbness and weakness of right arm, right leg, and right side of the face.
Client is awake, responsive, and follows commands. Appears confused and is unable to form words to answer questions
Right facial droop noted. Right hand grasp weak, left hand grasp strong. Day 7: Client is awake, alert, and oriented. Able to form some words to answer questions
Right facial droop. Right hand grasp weak, left hand grasp strong. Right leg weak. Ambulates with a walker and assistance.
Vital Signs
Vital Signs Day 1: Temperature 37.5°C (99.5° F) Blood pressure 198/96 mm Hg Heart rate 112/min Respiratory rate 22/min
Oxygen saturation 96% on room air Day 7:
Temperature 38° C (100,4° F) Blood pressure 166/70 mm Hg Heart rate 88/min
Respiratory rate 20/min
Oxygen saturation 97% on room air
Question 3 of 5
A nurse is caring for a client. For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.
| Options | Parkinson's Disease | Stroke | Multiple Sclerosis |
|---|---|---|---|
| Cognitive function | |||
| Speech | |||
| Mobility status | |||
| Blood pressure | |||
| Facial symmetry. |
Correct Answer:
Rationale:
Correct Answer:
Rationale: Cognitive function and Mobility status are consistent with Parkinson's disease due to characteristic symptoms like cognitive decline and mobility issues. Speech is related to stroke, often causing speech difficulties. Blood pressure is not specific to any of these diseases. Facial symmetry is not listed in the context of any specific disease process.
Extract:
Question 4 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Elevate the head of the bed. This intervention helps to promote venous drainage from the head, reducing intracranial pressure. Elevating the head of the bed also helps to improve cerebral blood flow.
Choices B, C, and D are incorrect. A brightly lit environment can increase stimulation and exacerbate symptoms. Encouraging a high intake of fluids can lead to fluid overload and worsen intracranial pressure. Teaching controlled coughing and deep breathing does not directly address the increased intracranial pressure concern.
Question 5 of 5
A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?
Correct Answer: C
Rationale:
Rationale: Guillain-Barré syndrome affects the peripheral nervous system, potentially leading to autonomic dysfunction causing neurogenic shock. This client is at risk due to nerve damage affecting blood vessel tone regulation. Chronic kidney disease (
A) is not directly related to neurogenic shock. Asthma (
B) does not typically lead to neurogenic shock. Severe burn injury (
D) can cause hypovolemic shock, not neurogenic shock. Other choices (E, F, G) are not provided.