ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 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-BarrΓ© 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 2 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.
Question 3 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.
Question 4 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 5 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Elevate the head of the bed. This intervention helps to promote venous drainage from the head, reducing intracranial pressure. Elevating the head of the bed also helps to improve cerebral blood flow.
Choices B, C, and D are incorrect. A brightly lit environment can increase stimulation and exacerbate symptoms. Encouraging a high intake of fluids can lead to fluid overload and worsen intracranial pressure. Teaching controlled coughing and deep breathing does not directly address the increased intracranial pressure concern.