ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Correct Answer: B
Rationale: The correct answer is B: Increased respiratory rate. This is the earliest indicator of shock because the body initially compensates by increasing respiratory rate to improve oxygenation and perfusion. Hypotension (
A) occurs later in shock as a result of decreased cardiac output. Anuria (
C) is a late sign of shock indicating renal failure. Decreased level of consciousness (
D) occurs when brain perfusion is severely compromised.
Therefore, increased respiratory rate is the first sign of the body's attempt to compensate for decreased perfusion in shock.
Extract:
Progress Notes
Day 1
Client presents with abrupt onset of stroke-like manifestations with right facial droop, slurred speech, ataxia, and decrease in level of consciousness.
CT scan indicates ischemic stroke. Thrombolytic therapy with alteplase 90 mg IV over 1 hr given without incident.
Day 2
Client alert and oriented to person, place, and time; speech slightly slurred, but comprehendible. Smile asymmetrical, right side of mouth drooping. Weakness to right arm and leg. Muscle strength with unequal grips, right hand weaker, muscle strength to right leg weaker. Swallow study reports reviewed.
Day 3
Client to be discharged with prescriptions for home health including speech, physical, and occupational therapy.
Client instructed on lifestyle changes to decrease stroke risk including medication therapy for atrial fibrillation, hypertension, hyperlipidemia. Client instructed on Level 3 dysphagia diet, as well as safe practices during mealtimes. On this diet the client can eat bite-sized pieces of moist foods with near- normal textures. They should avoid very hard, sticky, or crunchy foods, such as dried fruit or nuts.
Medical History
Atrial fibrillation Hypertension Obesity Hyperlipidemia
Diagnostic Results
Day 1
CT Scan:
Non-contrast CT of client who presents with facial droop, ataxia, and decrease in level of consciousness. No evidence of acute bleeding or lesions. Slight loss of normal gray matter/white matter differentiation may indicate early ischemic changes consistent with acute infarction.
Day 2
Swallow study.
Swallow study co texture. Results it
Question 2 of 5
A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Correct Answer: B,C,E,F
Rationale:
Correct Answer: B, C, E, F
Rationale:
B: Stopping watching TV while eating promotes mindful eating, aiding in digestion.
C: Having food consistency of pudding may be required for easier swallowing post-discharge.
E: Not drinking liquids with food prevents choking risk and aids digestion.
F: Avoiding nuts can prevent choking, especially if the client has swallowing difficulties.
Summary of Incorrect
Choices:
A: Looking up at the ceiling during swallowing is incorrect as it can lead to aspiration.
D: Having cream soups may not be suitable for certain conditions and can cause swallowing issues.
G: Incomplete information provided.
Extract:
Question 3 of 5
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
Correct Answer: D
Rationale:
Rationale: The correct answer is D. DIC is caused by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the clotting cascade, leading to the formation of microthrombi throughout the body. This consumption of clotting factors, including fibrinogen, results in bleeding tendencies. Lifelong heparin usage (
A) is not a treatment for DIC. DIC is characterized by low platelet count, not elevated (
B). DIC is an acquired condition, not a genetic disorder (
C) involving vitamin K deficiency.
Extract:
Nurses' Notes
Day 1:
Client admitted to the medical-surgical unit from the emergency department (ED). Client came to the ED after sudden onset of dizziness, numbness and weakness of right arm, right leg, and right side of the face.
Client is awake, responsive, and follows commands. Appears confused and is unable to form words to answer questions
Right facial droop noted. Right hand grasp weak, left hand grasp strong. Day 7: Client is awake, alert, and oriented. Able to form some words to answer questions
Right facial droop. Right hand grasp weak, left hand grasp strong. Right leg weak. Ambulates with a walker and assistance.
Vital Signs
Vital Signs Day 1: Temperature 37.5°C (99.5° F) Blood pressure 198/96 mm Hg Heart rate 112/min Respiratory rate 22/min
Oxygen saturation 96% on room air Day 7:
Temperature 38° C (100,4° F) Blood pressure 166/70 mm Hg Heart rate 88/min
Respiratory rate 20/min
Oxygen saturation 97% on room air
Question 4 of 5
A nurse is caring for a client. For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.
| Options | Parkinson's Disease | Stroke | Multiple Sclerosis |
|---|---|---|---|
| Cognitive function | |||
| Speech | |||
| Mobility status | |||
| Blood pressure | |||
| Facial symmetry. |
Correct Answer:
Rationale:
Correct Answer:
Rationale: Cognitive function and Mobility status are consistent with Parkinson's disease due to characteristic symptoms like cognitive decline and mobility issues. Speech is related to stroke, often causing speech difficulties. Blood pressure is not specific to any of these diseases. Facial symmetry is not listed in the context of any specific disease process.
Extract:
Question 5 of 5
A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?
Correct Answer: C
Rationale: The correct answer is C: Prevents dysrhythmias. Lidocaine is a Class IB antiarrhythmic medication commonly used to prevent and treat ventricular dysrhythmias, such as ventricular fibrillation and ventricular tachycardia. It works by stabilizing the cell membranes in the heart, reducing the excitability of cardiac cells and preventing abnormal electrical activity that can lead to life-threatening arrhythmias. The other options are incorrect because lidocaine does not slow intestinal motility (
A), relieve pain (
B), or dissolve blood clots (
D). It is important for the nurse to educate the client on the purpose of the medication to ensure understanding and adherence to the treatment plan.