a nurse is caring for a client who has been experiencing repeated tonic clonic seizures over the course of 30 minutes after maintaining the clients ai

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

A. Diazepam IV
B. Lorazepam PO
C. Diltiazem IV
D. Clonazepam PO

Correct answer: A

Rationale: In the scenario described, where the client has been experiencing repeated tonic-clonic seizures over an extended period, the priority is to administer a medication that can rapidly terminate the seizures. Diazepam is the medication of choice for status epilepticus due to its rapid onset of action within 10 minutes when administered intravenously. Lorazepam is also an option, but it is typically administered intravenously as well. Diltiazem is a calcium channel blocker used for conditions like hypertension and angina, not for seizures. Clonazepam, although used for seizures, is not the ideal choice in this acute situation due to its slower onset of action compared to benzodiazepines like diazepam and lorazepam.

2. What are the expected signs in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Fever and infection
C. Localized redness and swelling
D. Loss of sensation in the affected area

Correct answer: A

Rationale: In a patient with compartment syndrome, the classic signs include unrelieved pain, pallor, and pulselessness. These signs indicate compromised circulation and neurovascular function in the affected compartment. Fever and infection (Choice B) are not typical signs of compartment syndrome. Localized redness and swelling (Choice C) can be seen in other conditions like cellulitis but are not specific to compartment syndrome. Loss of sensation in the affected area (Choice D) may occur in some cases but is not as specific or consistent as unrelieved pain, pallor, and pulselessness in diagnosing compartment syndrome.

3. What is the first-line treatment for wheezing due to an allergic reaction?

A. Albuterol via nebulizer
B. Cromolyn via nebulizer
C. Methylprednisolone 100 mg IV
D. Aminophylline 500 mg IV

Correct answer: A

Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction because it acts quickly to open the airways by relaxing the muscles in the air passages. Cromolyn (Choice B) is used for asthma prevention rather than acute wheezing. Methylprednisolone (Choice C) and Aminophylline (Choice D) are not the first-line treatments for acute wheezing in the setting of an allergic reaction.

4. What dietary recommendation should be given to a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bedtime
C. Consume liquids with meals
D. Eat three large meals per day

Correct answer: A

Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. Mint and spicy foods can aggravate GERD symptoms by relaxing the lower esophageal sphincter and increasing stomach acid production, leading to acid reflux. Choices B, C, and D are incorrect. Eating large meals before bedtime can worsen GERD symptoms as lying down can promote acid reflux. Consuming liquids with meals can also exacerbate GERD by increasing stomach distension and pressure on the lower esophageal sphincter. Eating three large meals per day can overload the stomach and trigger acid reflux episodes in patients with GERD.

5. What should the nurse do for a patient experiencing abdominal cramping during enema administration?

A. Lower the height of the enema solution container
B. Stop the procedure and remove the tubing
C. Continue the enema at a slower rate
D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the solution. Choice B, stopping the procedure and removing the tubing, is incorrect as it is too drastic and may not address the cramping. Choice C, continuing the enema at a slower rate, may exacerbate the cramping if the flow rate is still too high. Choice D, increasing the flow of the enema solution, would worsen the cramping and is not the appropriate intervention.