ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. What are the main differences between a stroke caused by ischemia and one caused by hemorrhage?
- A. Blockage in a blood vessel supplying the brain
- B. Bleeding in the brain due to a ruptured aneurysm
- C. Administering thrombolytics if within the treatment window
- D. Avoiding anticoagulants and preparing for surgery
Correct answer: A
Rationale: The correct answer is A: "Blockage in a blood vessel supplying the brain." Ischemic stroke is caused by a blockage in a blood vessel supplying the brain, leading to reduced blood flow. Hemorrhagic stroke, on the other hand, is caused by bleeding in the brain due to a ruptured blood vessel. Choices B, C, and D are incorrect. Administering thrombolytics, avoiding anticoagulants, and preparing for surgery are specific management strategies that may apply to ischemic or hemorrhagic strokes but do not define the main differences between the two types of strokes.
2. A client has a new prescription for clonidine to treat hypertension. Which of the following instructions should the nurse include?
- A. Discontinue the medication if a rash develops.
- B. Expect increased salivation during the first few weeks of therapy.
- C. Avoid driving until the client's reaction to the medication is known.
- D. Stop the medication if you experience a dry mouth.
Correct answer: C
Rationale: The correct instruction for a client starting clonidine therapy for hypertension is to avoid driving until their reaction to the medication is known. Clonidine can cause drowsiness, so engaging in activities like driving that require alertness should be avoided until the individual understands how the medication affects them. Choices A, B, and D are incorrect because they do not address the specific side effect of drowsiness associated with clonidine that could impair driving abilities. Discontinuing the medication if a rash develops, expecting increased salivation, or stopping the medication for dry mouth are not primary concerns related to clonidine therapy for hypertension.
3. When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
- A. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.
- B. Discuss the reason for the use of insulin therapy during the immediate postoperative period.
- C. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
- D. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.
Correct answer: C
Rationale: The correct answer is C because the administration of prescribed lispro (Humalog) insulin before transporting the patient to surgery is a task that can be safely delegated to a licensed practical/vocational nurse (LPN/LVN). This action is within the scope of practice of an LPN/LVN and does not require independent nursing judgment. Choices A and B involve communicating and discussing important medical information, which are higher-level nursing actions typically performed by registered nurses. Choice D involves planning strategies to manage blood glucose levels postoperatively, which requires critical thinking and assessment skills usually performed by a registered nurse.
4. You are caring for Conrad who has a brain tumor and increased Intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?
- A. Administer bowel softener
- B. Position Conrad with his head turned toward the side of the tumor
- C. Provide sensory stimulation
- D. Encourage coughing and deep breathing
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
5. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
- A. All below
- B. Oliguria
- C. Confusion
- D. Pale extremities
Correct answer: A
Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.
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