what is the priority intervention when a patient experiences abdominal cramping during enema administration
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Nursing Elites

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. What is the priority intervention when a patient experiences abdominal cramping during enema administration?

Correct answer: A

Rationale: The correct answer is to lower the height of the enema solution container. This action can help relieve abdominal cramping by slowing the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is not the priority as adjusting the height of the container can often resolve the issue without needing to stop the procedure completely. Choice C, continuing the enema at a slower rate, may not address the immediate discomfort experienced by the patient. Choice D, increasing the flow of the enema solution, can exacerbate the cramping and should be avoided.

2. What are the characteristics of a thrombotic stroke?

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.

3. What dietary changes should be implemented for a patient with GERD?

Correct answer: A

Rationale: The correct answer is A: Avoid mint and spicy foods. Patients with GERD should avoid mint and spicy foods because they can increase gastric acid production, exacerbating symptoms. Choice B is incorrect because eating large meals before bedtime can worsen GERD symptoms due to lying down with a full stomach. Choice C is incorrect as consuming liquids with meals can lead to increased pressure on the lower esophageal sphincter, promoting acid reflux. Choice D is also incorrect as drinking milk as a snack is not recommended for GERD patients, as it may temporarily soothe symptoms but can ultimately stimulate acid production.

4. A patient who experienced an acute episode of gastritis should avoid which type of foods?

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in potassium. Potassium-rich foods can exacerbate gastritis symptoms by irritating the stomach lining. Sodium (choice B) is not directly related to gastritis symptoms. Increasing exercise (choice C) can be beneficial for overall health but may not directly impact gastritis. Drinking milk (choice D) can provide temporary relief for some individuals with gastritis due to its coating effect, but it is not a universal recommendation as it can worsen symptoms in some cases.

5. What are the early signs of compartment syndrome?

Correct answer: A

Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These signs are typical early indicators of compartment syndrome, suggesting compromised circulation. Choice B, localized redness and swelling, can be seen in conditions like cellulitis but are not specific to compartment syndrome. Choice C, fever and infection, are not characteristic early signs of compartment syndrome. Choice D, loss of sensation in the affected area, is more indicative of nerve damage rather than being one of the early signs of compartment syndrome.

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