ATI RN
ATI Nur211 Capstone Questions
Extract:
Medical History
0900:
Client had a left-hemisphere stroke with right-sided arm mild expressive aphasia. Client is able to ambulate with assistance. Client is alert to person and place but is unable to tell the date and time.
Nurses' Notes
1000:
Client is assisted out of bed to chair. Client is sitting upright eating breakfast. Bilateral breath sounds clear and present throughout. Client drools and clears throat when eating. Voice hoarse after swallowing.
1800:
Client coughing frequently. Breath sounds with crackles heard in right upper lobe.
Vital Signs
1000:
Temperature 37.2° C (99° F) Blood pressure 128/76 mm Hg Heart rate 86/min Respirations 18/min
Oxygen saturation 96% on room air
1800:
Temperature 39.6° C (103.3° F) Blood Pressure 118/78 mm Hg Heart Rate 104/min Respiration rate 24/min
Oxygenation saturation 92% on room air
Question 1 of 5
A nurse is caring for a client who has had a stroke. Select the 3 findings that require immediate follow-up.
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Drooling (
A) could indicate difficulty swallowing or airway compromise. A hoarse voice (
D) may suggest vocal cord dysfunction, which could lead to airway obstruction. Elevated temperature (E) could indicate infection, especially concerning in stroke patients. Blood pressure at 180 (
B) is high but not immediately life-threatening. Breath sounds at 1000 (
C) and missing options (F, G) are not directly related to immediate follow-up in this scenario.
Extract:
Question 2 of 5
Correct Answer:
Rationale:
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
Correct Answer:
Rationale:
Question 5 of 5
Correct Answer:
Rationale: