ATI Capstone Questions with correct answers

Discuss the rationale for a nurse placing a client with dysphagia in the high-fowler's position. Correct Answer - Placing a client in the high-fowler's position helps prevent aspiration during meals. In high fowler's, the client lies supine with the head of the bed elevated 60° to 90°. List two (2) examples of a primary skin lesion including description and example of each. Provide an example of appropriate documentation of the integumentary system. Correct Answer - Macule: Nonpalpable, skin color change, < 1 cm. Example: Freckle Papule: Palpable, circumscribed , < 0.5 cm. Example: Elevated nevus Nodule/tumor: Palpable, circumscribed, 0.5 cm or >. Example: Wart Vesicle: Serous fluid-filled, < 1 cm. Example: Blister Pustule: Pus-filled. Example: Acne Wheal: Palpable, irregular borders, edematous. Example: Insect bite EXAMPLE: Skin is pink, warm, and dry. Turgor is brisk and skin is elastic. Rough, thickened skin over heels, elbows, and knees; otherwise, skin is smooth. A 0.5 cm brown papule on right forearm and a 2.5 cm scar on left knee that is healed. Capillary refill is < 3 seconds. No edema is noted. A nurse is caring for an older adult client with dementia. What preventative measures should the nurse institute to reduce the risk of falls? Correct Answer - Answer Key Older adult clients may be at an increased risk for falls due to decreased strength, impaired mobility and balance, and endurance limitations combined with decreased sensory perception. Other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems (cerebral palsy, injury, multiple sclerosis) and cognitive dysfunction. Side effects of medications (orthostatic hypotension, drowsiness) also can increase