ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The halo device immobilizes the cervical spine to promote healing. Allowing movement, turning screws, or using talcum powder risks injury or skin breakdown.
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: Avoiding distractions, pudding-like consistency, separating liquids from solids, and avoiding nuts align with Level 3 dysphagia diet. Looking up and cream soups are incorrect.
Extract:
Question 3 of 5
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?
Correct Answer: B
Rationale: Packed RBCs restore blood volume and oxygen delivery in hypovolemic shock due to blood loss. Cryoprecipitates treat clotting disorders, albumin addresses fluid loss, and platelets manage thrombocytopenia.
Question 4 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: Tachycardia (160/min) is a compensatory mechanism in early shock. Hypokalemia and mottled skin occur later, and BP may remain normal initially.
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 5 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: Cognitive function: Parkinson’s (later dementia), stroke (acute changes), MS (subtle deficits). Speech: Parkinson’s (hypophonia), stroke (aphasia), MS (dysarthria). Mobility: Parkinson’s (bradykinesia), stroke (hemiparesis), MS (spasticity). BP: Stroke (risk factor). Facial symmetry: Parkinson’s (masked face), stroke (droop), MS (rare weakness).