ATI RN
ATI Nur211 Capstone Questions
Extract:
Nurses' Notes
0800:
Client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs continues. Yellow, watery emesis approximately 45 mL on gown; 2 to 5-second-long periods of apnea.
Vital Signs
1002:
Heart rate 86/min Respiratory rate 12/min
Oxygen saturation 86% on room air
Question 1 of 5
A nurse is caring for a client who has a seizure disorder. (Select all that apply.)
Correct Answer: A,C,E
Rationale:
Correct Answer: A, C, E
Rationale:
A: Administering supplemental oxygen helps maintain oxygen levels during a seizure, preventing hypoxia.
C: Timing the seizure duration is crucial for accurate documentation and evaluating the effectiveness of interventions.
E: Turning the client to the side helps prevent aspiration and ensures the airway remains clear.
Incorrect
Choices:
B: Restraining the client during a seizure can cause harm and increase the risk of injury.
D: Placing a tongue depressor in the client's mouth can lead to airway obstruction and injury.
In summary, administering oxygen, timing the seizure, and turning the client are essential interventions, while restraining and using tongue depressors are potentially harmful actions.
Extract:
Question 2 of 5
A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?
Correct Answer: D
Rationale: The correct answer is D: Decerebrate posturing. The nurse would document this finding by observing the patient's extended arms and legs, rigid posture, and clenched fists, indicating damage to the upper brainstem. Decerebrate posturing is a more severe form of abnormal posturing than decorticate posturing (choice
B), characterized by flexed arms and clenched fists. Spinal cord degeneration (choice
A) refers to progressive damage to the spinal cord, not a specific posture. Atypical hyperreflexia (choice
C) is not a recognized clinical term related to posture.
Therefore, the correct choice is D as it accurately describes the patient's posture and neurological condition.
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 caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?
Correct Answer: B
Rationale: The correct answer is B: Packed RBCs. In hypovolemic shock, there is a significant loss of blood volume leading to decreased oxygen-carrying capacity. Packed RBCs are the most appropriate choice as they directly increase the oxygen-carrying capacity of the blood, helping to improve tissue perfusion and oxygenation. Cryoprecipitates (
A) are used to manage bleeding disorders, not hypovolemic shock. Albumin (
C) is a colloid solution used for volume expansion but does not directly address the decreased oxygen-carrying capacity in hypovolemic shock. Platelets (
D) are used for clotting disorders, not for hypovolemic shock.
Question 5 of 5
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive thrombosis and bleeding. In DIC, there is widespread activation of the coagulation cascade leading to the formation of microthrombi in small blood vessels, causing tissue ischemia and organ dysfunction. This results in excessive clot formation (thrombosis) in some areas and simultaneous consumption of clotting factors and platelets, leading to bleeding in other areas. The other choices are incorrect because:
A) In DIC, there is consumption of clotting factors, leading to a decrease rather than an increase.
C) Platelet production may be increased initially to compensate for consumption, but it is not a progressive increase.
D) Sodium and fluid retention are not typical findings in DIC.