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
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 3 of 5
A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for mechanical ventilation. In a myasthenic crisis, respiratory muscles become severely weakened, leading to respiratory failure. Mechanical ventilation is crucial to support breathing and oxygenation. Administering sedatives (choice
A) can further depress respiratory function. Instructing pursed lip breathing (choice
B) may not be sufficient in severe cases. Administering a vasoconstrictor (choice
D) is not indicated in myasthenic crisis.
Question 4 of 5
A nurse is assessing a client in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?
Correct Answer: C
Rationale: The correct answer is C: Ocular trauma. Unequal pupil size, known as anisocoria, can be caused by trauma to the eye or head, leading to damage to the nerves controlling pupil size. This results in one pupil becoming fixed and dilated while the other constricts normally. Normal variation in pupil size (choice
A) is unlikely to cause such a drastic difference. Age-related changes (choice
B) typically result in bilateral changes rather than unilateral. Excessive light exposure (choice
D) can cause temporary pupil constriction but not fixed dilation and constriction pattern seen in the scenario.
Question 5 of 5
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Heart rate 160/min. In the compensatory stage of shock, the body attempts to maintain perfusion by increasing heart rate. This is a compensatory mechanism to ensure vital organs receive adequate blood flow. A heart rate of 160/min indicates the body's attempt to maintain cardiac output.
Choices B and C are incorrect as hypokalemia and mottled skin are not specific to the compensatory stage of shock.
Choice D is incorrect because a blood pressure of 115/68 mmHg is within normal range and may not necessarily indicate compensatory shock.