ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?
- A. After stroking the lateral area of the foot, the client's toes contract and draw together
- B. After hip flexion, the client is unable to extend their leg completely without pain
- C. The client's voluntary movement is not coordinated
- D. The client reports pain and stiffness when flexing their neck
Correct answer: B
Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.
2. An RN enters a patient�s room to place an indwelling urinary catheter, as ordered by the health-care professional. The client is alert and oriented and tells the RN he wants to leave the hospital now and not receive further treatment. Which of the following actions by the RN would be considered false imprisonment?
- A. The RN tells the client he is not allowed to leave until the physician has released him.
- B. The RN asks the client why he wishes to leave.
- C. The RN asks the client to explain what he understands about his medical diagnosis.
- D. The RN asks the client to sign an against medical advice discharge form.
Correct answer: A
Rationale: The RN tells the client he is not allowed to leave until the physician has released him would be considered false imprisonment.
3. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
- A. 1530 (3:30 PM)
- B. 1600 (4:00 PM)
- C. 1630 (4:30 PM)
- D. 1700 (5:00 PM)
Correct answer: C
Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.
4. A healthcare provider is evaluating a client who reports paresthesia of the hands and feet. The provider should identify this manifestation as an indication of which of the following dietary deficiencies?
- A. Iron
- B. Riboflavin
- C. Vitamin C
- D. Vitamin B12
Correct answer: D
Rationale: Correct! Vitamin B12 deficiency can lead to neurological symptoms, including paresthesia (tingling or numbness) of the hands and feet, due to its role in nerve health. Iron deficiency is more commonly associated with anemia symptoms like fatigue and pallor. Riboflavin deficiency can cause mouth and skin changes. Vitamin C deficiency is linked to scurvy symptoms like bleeding gums and easy bruising.
5. A nurse is providing care for a client with thrombocytopenia. Which of the following actions should the nurse include?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct answer: C
Rationale: The correct action for a nurse caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to bleeding problems. Providing a stool softener helps prevent constipation, which in turn prevents straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is not directly linked to managing thrombocytopenia.
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