ATI RN
ATI Nur211 Capstone Questions
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 1 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.
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 2 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 3 of 5
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. Hypokalemia leads to low potassium levels, affecting cardiac function. This can manifest as U wave prominence on EKG due to delayed repolarization of ventricles. Inverted P wave (choice
B) is seen in conditions like atrial ischemia, not specific to hypokalemia. Elevated ST segment (choice
C) indicates myocardial injury, not typically seen in hypokalemia. Wide QRS (choice
D) is seen in conditions like bundle branch blocks, not specific to hypokalemia. The other choices are not directly related to hypokalemia and are therefore incorrect.
Question 4 of 5
A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Decreasing level of consciousness. This would be reported immediately because it indicates a worsening condition and potential deterioration in the client's neurological status. It suggests increased intracranial pressure, which is a medical emergency requiring prompt intervention to prevent further brain injury.
Choices A, C, and D do not indicate an immediate threat to the client's life or neurological status. A pupil response (choice
A) within normal limits, a temporal headache (choice
C), and a Glasgow coma score of 13 (choice
D) are concerning but do not signify an acute decline in neurological status that necessitates immediate action.
Question 5 of 5
A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?
Correct Answer: C
Rationale: The correct answer is C: Prevents dysrhythmias. Lidocaine is a Class IB antiarrhythmic medication commonly used to prevent and treat ventricular dysrhythmias, such as ventricular fibrillation and ventricular tachycardia. It works by stabilizing the cell membranes in the heart, reducing the excitability of cardiac cells and preventing abnormal electrical activity that can lead to life-threatening arrhythmias. The other options are incorrect because lidocaine does not slow intestinal motility (
A), relieve pain (
B), or dissolve blood clots (
D). It is important for the nurse to educate the client on the purpose of the medication to ensure understanding and adherence to the treatment plan.