Med Surg ATI Capstone Question And
Answers
A nurse in the critical care unit is completing an admission assessment of
a client who has a gunshot wound to the head. Which of the following
assessment findings are indicative of increased ICP? (Select all that apply)
A. Headache
B. Dilated pupils
C. Tachycardia
D. Decorticate posturing
E. Hypotension - -A, B, D
- A nurse in the ED is assessing a client who is unresponsive. The client's
partner states, "He was pulling weeds in the yard and slumped to the
ground." Which of the following techniques should the nurse use to open
the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - -A
- A nurse in the emergency department is caring for a client who fell
through the ice on a pond and is unresponsive and breathing slowly.
Which of the following actions should the nurse take? (Select all that
apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - -A, C, D, E
- A nurse is assessing a client for changes in the level of consciousness
using the GCS. The client opens his eyes when spoken to, speaks
incoherently, and moves his extremities when pain is applied. Which of
the following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - -B
, - A nurse is assessing a client who has a chest tube and drainage
system in place. Which of the following are expected findings? (Select all
that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with
inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - -B, C
- A nurse is assessing a client who has a seizure disorder. The client
reports he thinks he is about to have a seizure. Which of the following
actions should the nurse implement? (Select all that apply)
A. Provide privacy
B. Ease the client to the floor if standing
C. Move furniture away from the client
D. Loosen the client's clothing
E. Protect the client's head with padding
F. Restrain the client - -A, B, C, D, E
- A nurse is assessing a client who has experienced a left-hemispheric
stroke. Which of the following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception - -C
- A nurse is assessing a client who reports severe headache and a stiff
neck. The nurse's assessment reveals positive Kernig's and Brudzinski's
signs. Which of the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
D. Decrease bright lights - -B
- A nurse is assessing for the presence of Brudzinski's sign in a client
who has suspected meningitis. Which of the following actions should the
nurse take when performing this technique? (Select all that apply)
A. Place client in supine position
B. Flex client's hip and knee
C. Place hands behind the client's neck
D. Bend client's head toward chest
E. Straighten the client's flexed leg at the knee - -A, C, D
Answers
A nurse in the critical care unit is completing an admission assessment of
a client who has a gunshot wound to the head. Which of the following
assessment findings are indicative of increased ICP? (Select all that apply)
A. Headache
B. Dilated pupils
C. Tachycardia
D. Decorticate posturing
E. Hypotension - -A, B, D
- A nurse in the ED is assessing a client who is unresponsive. The client's
partner states, "He was pulling weeds in the yard and slumped to the
ground." Which of the following techniques should the nurse use to open
the client's airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head - -A
- A nurse in the emergency department is caring for a client who fell
through the ice on a pond and is unresponsive and breathing slowly.
Which of the following actions should the nurse take? (Select all that
apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Apply a heat lamp
E. Infuse warmed IV fluids - -A, C, D, E
- A nurse is assessing a client for changes in the level of consciousness
using the GCS. The client opens his eyes when spoken to, speaks
incoherently, and moves his extremities when pain is applied. Which of
the following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - -B
, - A nurse is assessing a client who has a chest tube and drainage
system in place. Which of the following are expected findings? (Select all
that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with
inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - -B, C
- A nurse is assessing a client who has a seizure disorder. The client
reports he thinks he is about to have a seizure. Which of the following
actions should the nurse implement? (Select all that apply)
A. Provide privacy
B. Ease the client to the floor if standing
C. Move furniture away from the client
D. Loosen the client's clothing
E. Protect the client's head with padding
F. Restrain the client - -A, B, C, D, E
- A nurse is assessing a client who has experienced a left-hemispheric
stroke. Which of the following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception - -C
- A nurse is assessing a client who reports severe headache and a stiff
neck. The nurse's assessment reveals positive Kernig's and Brudzinski's
signs. Which of the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
D. Decrease bright lights - -B
- A nurse is assessing for the presence of Brudzinski's sign in a client
who has suspected meningitis. Which of the following actions should the
nurse take when performing this technique? (Select all that apply)
A. Place client in supine position
B. Flex client's hip and knee
C. Place hands behind the client's neck
D. Bend client's head toward chest
E. Straighten the client's flexed leg at the knee - -A, C, D
