ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not wash my hair prior to the procedure.
- B. I will receive a sedative 1 hour before the procedure.
- C. I should avoid eating prior to the procedure.
- D. I will be exposed to flashes of light during the procedure.
Correct answer: D
Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.
2. What are the early signs of hypokalemia on an ECG?
- A. Flattened T waves
- B. Elevated ST segments
- C. Prominent U waves
- D. Widened QRS complex
Correct answer: A
Rationale: Flattened T waves are an early sign of hypokalemia on an ECG. In hypokalemia, the T waves may flatten and eventually invert. Elevated ST segments are not typically associated with hypokalemia. Prominent U waves are seen in conditions like hypokalemia, but they are not considered an early sign. A widened QRS complex is more commonly associated with hyperkalemia rather than hypokalemia.
3. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?
- A. Keep a padded tongue depressor near the bedside
- B. Place a pillow under the client's head during a seizure
- C. Administer diazepam intravenously at the onset of seizures
- D. Position the client on their side during a seizure
Correct answer: D
Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.
4. What is an escharotomy, and why is it performed?
- A. To relieve pressure and improve circulation in burn injuries
- B. To reduce pain in the affected area
- C. To remove necrotic tissue from a wound
- D. To remove fluid from a burn wound
Correct answer: A
Rationale: An escharotomy is a surgical procedure performed to relieve pressure and improve circulation in areas affected by deep burns. Choice A is the correct answer because the primary goal of an escharotomy is to prevent compartment syndrome caused by increased pressure within the affected tissues. Choices B, C, and D are incorrect because an escharotomy is not primarily performed to reduce pain, remove necrotic tissue, or drain fluid from a burn wound, but to address the specific issue of compromised blood flow and pressure within deep burn injuries.
5. During an escharotomy on a patient with a burn injury, what is the purpose of this procedure?
- A. To release pressure and improve circulation in the affected area
- B. To remove dead tissue from the burn area
- C. To improve breathing by reducing skin tightness
- D. To prevent infection in the burned area
Correct answer: A
Rationale: Corrected Question: During an escharotomy on a patient with a burn injury, the purpose of this procedure is to release pressure and improve circulation in the affected area. This intervention is crucial in severe burns where the formation of eschar (dead tissue) can lead to increased pressure, compromising circulation and potentially causing further tissue damage. Choices B, C, and D are incorrect because escharotomy specifically aims to address pressure and circulation issues in severe burn injuries, rather than removing dead tissue, improving breathing, or preventing infection.
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