ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?
- A. It is okay to not want to touch the burned areas of your body.
- B. Cosmetic surgery should be performed within the next year to be effective.
- C. Reconstructive surgery can completely restore your previous appearance.
- D. It could be helpful for you to attend a support group for people who have burn injuries.
Correct answer: D
Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.
2. A client with major depressive disorder is prescribed an antidepressant. Which of the following instructions should the nurse include in the teaching? Select the one that does not apply.
- A. It may take several weeks for the medication to take effect
- B. Avoid alcohol while taking this medication
- C. Discontinue the medication abruptly
- D. You may experience an increase in energy before your mood improves
Correct answer: C
Rationale: Teaching for a client prescribed an antidepressant should include several key instructions. Firstly, it's important to inform the client that it may take several weeks for the medication to take effect, so they should be patient. Secondly, they should be advised to avoid alcohol while taking the medication as it can interact negatively with antidepressants. Additionally, abrupt discontinuation of antidepressants can lead to withdrawal symptoms and should be avoided. Lastly, clients may experience an increase in energy before their mood improves, which is a common effect of some antidepressants. Regular blood tests are not typically required for most antidepressants, but adherence to the prescribed regimen and reporting any concerning side effects to the healthcare provider are crucial.
3. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
- A. a 45-degree angle
- B. a 60-degree angle
- C. a 75-degree angle
- D. a 90-degree angle
Correct answer: D
Rationale: Intramuscular injections in the ventrogluteal site should be administered at a 90-degree angle. This angle ensures that the medication reaches the muscle tissue effectively. Angles less than 90 degrees can cause subcutaneous injection instead of intramuscular, leading to slower absorption of the medication. Angles greater than 90 degrees risk hitting bone or nerves, causing unnecessary pain or injury. Therefore, the correct angle for administering intramuscular injections in the ventrogluteal site is 90 degrees.
4. A nurse is providing discharge teaching for a client with a prescription for home oxygen therapy. Which instruction should the nurse include?
- A. Increase the oxygen flow rate when shortness of breath occurs
- B. Keep oxygen tubing away from heat sources
- C. Wear synthetic fabrics to prevent static
- D. Turn off the oxygen when not in use
Correct answer: B
Rationale: The correct instruction for a client with home oxygen therapy is to keep oxygen tubing away from heat sources to prevent fires and other hazards. Option A is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Option C is incorrect as synthetic fabrics can generate static electricity, which is a fire hazard. Option D is incorrect as oxygen should be left on as prescribed unless advised otherwise.
5. Which parental statement indicates correct understanding of information presented regarding the prevention of iron deficiency anemia in infants?
- A. "We will add green leafy vegetables to our child’s low-iron formula."
- B. "We will discontinue the use of vitamin C supplements by 6 months of age."
- C. "We will begin an iron-fortified infant cereal at 4 to 6 months of age."
- D. "We will introduce cow’s milk by 6 months of age."
Correct answer: C
Rationale: The correct answer is C. Introducing iron-fortified cereal between 4 to 6 months of age is a recommended practice to prevent iron deficiency anemia in infants. Iron-fortified infant cereals are a good source of iron for infants. Choices A and B are incorrect because adding green leafy vegetables to low-iron formula and discontinuing vitamin C supplements do not directly address the prevention of iron deficiency anemia. Choice D is incorrect because cow's milk should be avoided before 12 months of age as it is low in iron and can lead to intestinal blood loss, increasing the risk of iron deficiency anemia.
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