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 is the first action a healthcare provider should take for a patient with possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Get IV access
- C. Auscultate heart sounds
- D. Obtain cardiac enzymes
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the initial priority action for a patient with possible acute coronary syndrome. Nitroglycerin helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart muscle. This helps in relieving symptoms and preventing further damage to the heart. Establishing IV access, auscultating heart sounds, and obtaining cardiac enzymes are important steps in the assessment and management of acute coronary syndrome but are not the first actions to be taken. IV access may be needed for administering medications or fluids, auscultating heart sounds helps in assessing the heart's function, and obtaining cardiac enzymes aids in diagnosing a heart attack.
3. What are the expected manifestations in a patient experiencing a thrombotic stroke?
- A. Sudden numbness or loss of function on one side of the body
- B. Sudden loss of consciousness and seizure
- C. Gradual onset of difficulty speaking
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: The correct manifestation in a patient experiencing a thrombotic stroke is sudden numbness or loss of function on one side of the body. This is due to the blockage of a blood vessel by a clot, leading to a lack of blood flow to a specific part of the brain. Choices B, C, and D are incorrect. Sudden loss of consciousness and seizure are more commonly associated with hemorrhagic strokes. Gradual onset of difficulty speaking is often seen in ischemic strokes affecting language areas, not specifically in thrombotic strokes. Loss of sensation in the affected limb is more indicative of sensory nerve damage rather than the motor deficits seen in thrombotic strokes.
4. What are the characteristics of a thrombotic stroke?
- A. Gradual onset over minutes to hours
- B. Numbness on one side of the body
- C. Associated with a loss of consciousness
- D. Associated with seizures and convulsions
Correct answer: A
Rationale: The correct answer is A. Thrombotic strokes typically have a gradual onset over minutes to hours as they result from a clot obstructing blood flow. Choice B, numbness on one side of the body, is more commonly associated with an ischemic stroke rather than specifically a thrombotic stroke. Choice C, loss of consciousness, is not a defining characteristic of a thrombotic stroke. Choice D, seizures and convulsions, are more commonly seen in hemorrhagic strokes rather than thrombotic strokes.
5. What signs indicate increased intracranial pressure (IICP)?
- A. Restlessness, irritability, and confusion
- B. Sudden onset of seizures
- C. Bradycardia and altered pupil response
- D. Loss of consciousness
Correct answer: A
Rationale: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These symptoms occur due to the brain's increased pressure within the skull. Sudden onset of seizures (Choice B) is not typically associated with increased intracranial pressure. Bradycardia and altered pupil response (Choice C) are signs of advanced or worsening IICP. Loss of consciousness (Choice D) is a late sign of increased intracranial pressure.
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