ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?
Correct Answer: B
Rationale: The correct answer is B - Muscle contractions become progressively stronger. The Tensilon test involves administering edrophonium, which temporarily inhibits the breakdown of acetylcholine at the neuromuscular junction. In myasthenia gravis, where there is a deficiency of acetylcholine receptors, this results in a temporary improvement in muscle strength and contraction.
Therefore, if the muscle contractions become progressively stronger after the Tensilon test, it indicates a positive result, confirming the diagnosis of myasthenia gravis.
Choices A, C, and D are incorrect because they do not align with the expected response of muscle strength improvement in a positive Tensilon test.
Question 2 of 5
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?
Correct Answer: D
Rationale: The correct answer is D: Increased heart rate. In hypovolemic shock, the body tries to compensate for decreased blood volume by increasing heart rate to maintain adequate circulation. This is a result of the body's attempt to deliver oxygen and nutrients to vital organs despite the reduced blood volume. The other choices are incorrect because: A: Widening pulse pressure is not typically seen in hypovolemic shock; B: Pulse oximetry of 96% indicates adequate oxygen saturation, not a specific indicator of hypovolemic shock; C: Increased deep tendon reflexes are not typically associated with hypovolemic shock.
Question 3 of 5
A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?
Correct Answer: A
Rationale: The correct answer is A: Flexion and internal rotation of upper extremities. Decorticate posturing is characterized by the arms flexing inward towards the core of the body with internal rotation. This occurs due to damage to the corticospinal tracts. Other choices are incorrect because decerebrate posturing (extension and external rotation of upper extremities) is associated with damage to the brainstem. Extension and internal rotation (
Choice
C) and external rotation (
Choice
D) are not typical findings in decorticate posturing.
Question 4 of 5
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: Defibrillation. In ventricular fibrillation, the heart is quivering and not effectively pumping blood. Defibrillation is the priority to restore normal heart rhythm by delivering an electrical shock to the heart. This is crucial to improve the chances of survival. Amiodarone (
A) and epinephrine (
B) may be used after defibrillation but are not the initial priority. Airway management (
D) is important but comes after restoring cardiac function.
Question 5 of 5
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Position the child laterally. This is the correct action because it helps prevent aspiration and maintains a clear airway during the seizure. Placing the child on their side also reduces the risk of injury. Restraint (choice
A) can lead to further harm. Using a padded tongue blade (choice
B) is unnecessary and may increase the risk of injury. Attempting to stop the seizure (choice
D) is not within the nurse's scope of practice and can be dangerous.