ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What are the expected symptoms in a patient with 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: A thrombotic stroke typically presents with a gradual loss of function on one side of the body. This gradual onset distinguishes it from a hemorrhagic stroke, which often manifests with sudden and severe symptoms like loss of consciousness (choice B), severe headache and confusion (choice C), or loss of sensation in the affected limb (choice D). Therefore, choices B, C, and D are not typically associated with thrombotic strokes.
2. A nurse is planning care for a client who has acute post-streptococcal glomerulonephritis. Which of the following interventions should the nurse include in the client's plan?
- A. Encourage a high-protein diet
- B. Increase the client's fluid intake
- C. Administer diuretics
- D. Weigh the client twice a week
Correct answer: C
Rationale: Administering diuretics is a crucial intervention for a client with acute post-streptococcal glomerulonephritis as it helps reduce edema by increasing urine output and managing symptoms of glomerulonephritis. Encouraging a high-protein diet (Choice A) is not recommended in this case because it can put additional stress on the kidneys. Increasing fluid intake (Choice B) may worsen edema in these clients. Weighing the client twice a week (Choice D) is important for monitoring fluid balance but is not as immediate and directly beneficial as administering diuretics.
3. A client scheduled for electromyography (EMG) will have small needle electrodes inserted into the muscles. What should the nurse include in the teaching?
- A. You will receive a fixed dose of radioisotope 2 hours before the procedure.
- B. Momentary flushing will occur at the beginning of the procedure.
- C. You should inform your provider if you are claustrophobic.
- D. You should expect insertion of small needle electrodes into the muscles.
Correct answer: D
Rationale: The correct answer is D. During an electromyography (EMG) procedure, small needle electrodes are inserted into the muscles to assess muscle weakness and nerve responses. Choices A, B, and C are incorrect because radioisotope is not used in EMG, flushing is not a typical occurrence, and claustrophobia is more relevant for imaging procedures like MRI or CT scans, not EMG.
4. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?
- A. 1 packet of reconstituted dry onion soup
- B. 3 oz of lean cured ham
- C. 3 oz of chicken breast
- D. ½ cup of canned baked beans
Correct answer: C
Rationale: For a client with hypertension, a low sodium diet is recommended to help control blood pressure. Among the food choices provided, the best option is 3 oz of chicken breast. Chicken breast is lean protein with lower sodium content compared to other choices. It is a healthier option for managing hypertension. Reconstituted dry onion soup (Choice A) and canned baked beans (Choice D) typically contain higher amounts of sodium, which can be detrimental for blood pressure management. Lean cured ham (Choice B) also tends to have a higher sodium content, making it less suitable for a client with hypertension.
5. What are the expected symptoms in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and redness
- C. Fever and swelling
- D. Weakness and fatigue
Correct answer: A
Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These symptoms are classic signs of compartment syndrome, which is a serious condition characterized by reduced circulation in a closed muscle compartment. The pain is typically severe and disproportionate to the injury, and if left untreated, it can lead to tissue damage and loss of function. Choices B, C, and D are incorrect because they do not represent the hallmark symptoms of compartment syndrome. Localized swelling and redness may be present but are not specific to this condition. Fever and swelling are more indicative of inflammation or infection, while weakness and fatigue are nonspecific and do not typically occur in isolation in compartment syndrome.
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