ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3- 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: B
Rationale: The correct answer is B: Respiratory alkalosis. In this scenario, the client is experiencing respiratory alkalosis due to hyperventilation. Hyperventilation leads to excessive loss of carbon dioxide, causing a decrease in hydrogen ion concentration and an increase in pH levels. Choices A, C, and D are incorrect. Respiratory acidosis is characterized by high PaCO2 and low pH. Metabolic acidosis is associated with low HCO3- levels and low pH. Metabolic alkalosis is marked by high HCO3- levels and high pH. In this case, the ABG results indicate respiratory alkalosis.
2. All of the following are seen in a child with measles. Which one is not?
- A. Reddened eyes
- B. Coryza
- C. Pustule
- D. Cough
Correct answer: C
Rationale: Measles typically presents with symptoms like reddened eyes, coryza (inflammation of the mucous membrane in the nose), and cough. However, pustules are not a common symptom of measles. Pustules are more characteristic of conditions like chickenpox rather than measles. Understanding these distinctions is crucial for accurate diagnosis and appropriate treatment.
3. Which is an essential aspect of developing a community health intervention?
- A. Assessing the availability of local health resources
- B. Engaging policymakers in the planning process
- C. Developing culturally appropriate health materials
- D. Allocating funding for health services
Correct answer: A
Rationale: Assessing the availability of local health resources is a crucial step in the development of a community health intervention. By understanding the resources already present in the community, intervention strategies can be tailored to effectively address the specific health needs of the population. This assessment helps in identifying gaps, strengths, and areas for improvement, ensuring that the intervention is well-informed and targeted towards improving community health outcomes.
4. What are some common methods used to study genetic influences on behavior?
- A. Genetic influences are studied only through twin studies.
- B. Common methods include twin studies, adoption studies, and gene mapping.
- C. Genetic influences on behavior are only studied through family history.
- D. Genetic influences on behavior are not well understood.
Correct answer: B
Rationale: Common methods used to study genetic influences on behavior include twin studies, adoption studies, and gene mapping. Twin studies help to compare the similarities between identical and fraternal twins to estimate the heritability of a trait. Adoption studies look at the similarities between adopted children and their biological and adoptive parents to determine genetic influences. Gene mapping involves identifying specific genes associated with certain behaviors. Choices A, C, and D are incorrect because genetic influences on behavior are not solely studied through twin studies or family history, and while the understanding of genetic influences may vary, there are established methods to study them.
5. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?
- A. Assess the client’s vital signs
- B. Start an IV with an 18-gauge needle
- C. Begin iced saline lavage
- D. A, B
Correct answer: D
Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client’s vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.
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