ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Speak to the client about one idea at a time. Global aphasia impairs the ability to understand and communicate effectively. By speaking about one idea at a time, the nurse helps the client focus and process information easier. This approach reduces confusion and frustration for the client.
Choice A is incorrect because multitasking can overwhelm someone with global aphasia.
Choice C is incorrect as using multiple forms of communication may be too challenging.
Choice D is incorrect as limiting questions to yes and no may not address the client's needs fully.
Question 2 of 5
A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAP). The graduate nurse demonstrates correct understanding when he states which of the following:
Correct Answer: D
Rationale: The correct answer is D: Lower blood volume lowers MAP. Mean Arterial Pressure (MAP) is determined by cardiac output and systemic vascular resistance. Severe blood loss results in decreased blood volume, leading to a decrease in cardiac output. With lower cardiac output, there is less blood being pumped into the arteries, resulting in lower pressure exerted on the arterial walls, hence lowering the MAP.
Choices A and B are incorrect as severe blood loss reduces cardiac output and would not raise it or cause vasoconstriction.
Choice C is incorrect as there is a direct correlation between blood loss and MAP.
Question 3 of 5
A nurse assesses a client with a brain injury. The client opens his eyes when the nurse calls his name, does not understand questions, and brings his arm up in response to a trapezius squeeze by the nurse. How would the nurse document this client's assessment using the Glasgow Coma Scale?
Correct Answer: D
Rationale: The correct answer is D: 9. The Glasgow Coma Scale (GCS) assesses eye opening, verbal response, and motor response. In this scenario, the client opens his eyes in response to a stimulus (4 points), has no verbal response (1 point), and exhibits localizing pain motor response by bringing his arm up to the trapezius squeeze (4 points). This totals 9 points on the GCS, indicating a moderate level of consciousness.
Choices A, C, and G are incorrect as they do not accurately reflect the client's assessment findings.
Choice B is incorrect as a score of 1 on the GCS indicates the lowest level of consciousness.
Question 4 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.
Question 5 of 5
A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Measure the client's apical pulse. This is crucial before administering digoxin because it helps monitor the client's heart rate, as digoxin can cause bradycardia or dysrhythmias. Monitoring the apical pulse ensures the heart rate is within the safe range for administering the medication.
The other choices are incorrect because:
B: Measuring the client's blood pressure is not specifically necessary before administering digoxin, as the primary concern is monitoring the heart rate.
C: Offering the client a light snack is irrelevant to the administration of digoxin and does not impact the medication's effectiveness or safety.
D: Weighing the client is not directly related to administering digoxin and does not provide information necessary for ensuring safe administration.