ATI RN
ATI Capstone Week 10 Exam Questions
Extract:
Question 1 of 5
A nurse is providing care to a child who has an allergy to eggs. The nurse should clarify a prescription for which of the following immunizations?
Correct Answer: D
Rationale: The correct answer is D: Influenza, live attenuated (LAIV). Children with an egg allergy should not receive the LAIV vaccine as it is produced in eggs and may trigger an allergic reaction. The other options (A, B,
C) are not contraindicated in children with egg allergies. IPV, HepB, and Hib vaccines do not contain egg proteins and are safe for children with egg allergies.
Therefore, the nurse should clarify the prescription for Influenza LAIV to ensure the child receives a safe alternative vaccine.
Question 2 of 5
A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?
Correct Answer: A
Rationale:
Correct Answer: A - Connective tissue
Rationale: Systemic lupus erythematosus (SLE) is an autoimmune disease where the immune system attacks healthy tissue. Connective tissue is the primary target in SLE. This tissue includes joints, skin, and organs. In SLE, immune complexes deposit in connective tissue, leading to inflammation and damage. The other choices are incorrect because SLE primarily affects the connective tissue rather than the peripheral vascular system, lymphatic system, or skeletal tissue.
Question 3 of 5
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Restrict head movement. This instruction is crucial post-retinal detachment surgery to prevent any sudden movements that could potentially disrupt the surgical site and worsen the detachment. Cool compresses (
A) are not recommended as they could increase intraocular pressure. Eye drops to constrict pupils (
B) are not typically prescribed post-surgery for retinal detachment. Keeping both eyes patched (
D) is not necessary as it can obstruct vision in the unaffected eye.
Question 4 of 5
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?
Correct Answer: B
Rationale: The correct answer is B: FLACC. The FLACC scale is recommended for infants and young children who cannot verbally communicate their pain level. It assesses Face, Legs, Activity, Cry, and Consolability. This scale is particularly useful for postoperative pain assessment in infants like the 6-month-old in this scenario. The Face component looks for facial expressions indicating pain, Legs assesses the child's leg movement, Activity evaluates overall body movement, Cry measures the infant's vocalization, and Consolability checks if the infant can be comforted. The other choices are not as suitable for infants or postoperative pain assessment. Visual Analog Scale requires self-reporting, Oucher and Faces scales are more appropriate for older children who can point to a face or number to indicate pain level.
Question 5 of 5
A client calls the health care clinic and asks the nurse to describe the first signs of Lyme disease. The nurse informs the client to watch for which signs/symptoms of stage I Lyme disease?
Correct Answer: C
Rationale: The correct answer is C: Rash symptoms. In stage I Lyme disease, a characteristic symptom is a circular rash called erythema migrans. This rash typically appears at the site of the tick bite and expands over time. It is important for the client to watch for this specific rash as it is a hallmark sign of early Lyme disease. Headaches and blurred vision (choice
A) are not typically associated with early Lyme disease. Tremors and weakness (choice
B) are more commonly seen in later stages of the disease. Painful joints (choice
D) may occur in later stages as well but are not specific to stage I Lyme disease.