ATI RN
ATI Nur211 Capstone Questions
Extract:
Question 1 of 5
What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: The correct signs and symptoms for meningitis include fever and chills due to systemic infection, nuchal rigidity from meningeal irritation, severe headache from increased intracranial pressure, and Brudzinski's sign, which indicates meningeal irritation when the neck is flexed. Bradycardia is not a typical sign of meningitis. The summary of why the other choices are incorrect is that they do not align with the classic signs and symptoms of meningitis, which are mainly related to systemic infection and meningeal irritation.
Question 2 of 5
A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Speak to the client about one idea at a time. Global aphasia impairs the ability to understand and communicate effectively. By speaking about one idea at a time, the nurse helps the client focus and process information easier. This approach reduces confusion and frustration for the client.
Choice A is incorrect because multitasking can overwhelm someone with global aphasia.
Choice C is incorrect as using multiple forms of communication may be too challenging.
Choice D is incorrect as limiting questions to yes and no may not address the client's needs fully.
Question 3 of 5
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Hypovolemia. A low CVP in a client with multiple traumas indicates decreased blood volume, leading to hypovolemia. This can be due to blood loss from trauma. Other choices are incorrect: A (Fluid overload) would result in elevated CVP, C (Left ventricular failure) would typically show an elevated CVP, and D (Intracardiac shunt) would not directly affect CVP. It is crucial for the nurse to recognize hypovolemia promptly in trauma patients to initiate appropriate interventions.
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 assesses a client with a brain injury. The client opens his eyes when the nurse calls his name, does not understand questions, and brings his arm up in response to a trapezius squeeze by the nurse. How would the nurse document this client's assessment using the Glasgow Coma Scale?
Correct Answer: D
Rationale: The correct answer is D: 9. The Glasgow Coma Scale (GCS) assesses eye opening, verbal response, and motor response. In this scenario, the client opens his eyes in response to a stimulus (4 points), has no verbal response (1 point), and exhibits localizing pain motor response by bringing his arm up to the trapezius squeeze (4 points). This totals 9 points on the GCS, indicating a moderate level of consciousness.
Choices A, C, and G are incorrect as they do not accurately reflect the client's assessment findings.
Choice B is incorrect as a score of 1 on the GCS indicates the lowest level of consciousness.