a nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine which of the fol

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ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

A. Inspect the pin site every 4 hours
B. Monitor the client's skin under the halo vest
C. Ensure two personnel hold the halo device when repositioning the client
D. Apply powder to the client's skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

2. What are the expected symptoms of a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Severe headache and confusion
D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' In a thrombotic stroke, a clot blocks a cerebral artery, leading to a gradual onset of symptoms such as weakness, numbness, or paralysis on one side of the body. Choice B, 'Sudden loss of consciousness,' is more characteristic of a hemorrhagic stroke. Choice C, 'Severe headache and confusion,' are often associated with subarachnoid hemorrhage rather than thrombotic stroke. Choice D, 'Loss of sensation in the affected limb,' is not a typical symptom pattern for a thrombotic stroke, which usually presents with motor deficits.

3. What is the first medication to give to a patient experiencing wheezing due to an allergic reaction?

A. Albuterol via nebulizer
B. Cromolyn 20 mg 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 due to its rapid action in opening airways. Cromolyn (Choice B) is used for prevention rather than acute treatment. Methylprednisolone (Choice C) and Aminophylline (Choice D) are not the first-line treatments for acute wheezing in allergic reactions.

4. A patient reports abdominal cramping after enema administration. What is the appropriate action?

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

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

5. What is the first intervention for a patient admitted with unstable angina?

A. Administer nitroglycerin
B. Obtain cardiac enzymes
C. Start IV fluids
D. Monitor for chest pain

Correct answer: A

Rationale: The correct first intervention for a patient admitted with unstable angina is to administer nitroglycerin. Nitroglycerin helps to relieve chest pain by dilating blood vessels and increasing blood flow to the heart, thereby reducing cardiac workload. This intervention aims to alleviate symptoms and prevent further cardiac damage. Obtaining cardiac enzymes (Choice B) is important for diagnosing a myocardial infarction but is not the initial intervention for unstable angina. Starting IV fluids (Choice C) may be indicated in specific cases like hypovolemia but is not the primary intervention for unstable angina. Monitoring for chest pain (Choice D) is essential but taking action to alleviate the pain, like administering nitroglycerin, is the primary focus in the initial management of unstable angina.