ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 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.
Question 2 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.
Question 3 of 5
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. Hypokalemia leads to low potassium levels, affecting cardiac function. This can manifest as U wave prominence on EKG due to delayed repolarization of ventricles. Inverted P wave (choice
B) is seen in conditions like atrial ischemia, not specific to hypokalemia. Elevated ST segment (choice
C) indicates myocardial injury, not typically seen in hypokalemia. Wide QRS (choice
D) is seen in conditions like bundle branch blocks, not specific to hypokalemia. The other choices are not directly related to hypokalemia and are therefore incorrect.
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 assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?
Correct Answer: D
Rationale: The correct answer is D: Dorsiflexion of the great toe. Babinski's sign is an abnormal response where the great toe extends and the other toes fan out when the sole of the foot is stroked. In this scenario, a client with an unrepaired femur fracture suddenly becoming stuporous may indicate increased intracranial pressure. Assessing for Babinski's sign helps in detecting neurological abnormalities.
Choices A, B, and C are unrelated to Babinski's sign and are not indicative of neurological issues. Jerking contractions of the head and neck, pinpoint pupils, and pronation of the arms are not specific to Babinski's sign and do not provide relevant information in this situation.