ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
- A. Inspect the pin site every 4 hours
- B. Monitor the client's skin under the halo vest
- C. Ensure two personnel hold the halo device when repositioning the client
- D. Apply powder to the client's skin under the vest to decrease itching
Correct answer: B
Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.
2. Which of the following is an example of a communicable disease?
- A. Diabetes
- B. Hypertension
- C. HIV/AIDS
- D. Cholera
Correct answer: D
Rationale: Cholera is caused by the bacterium Vibrio cholerae and is transmitted through contaminated water or food. It spreads rapidly in areas with poor sanitation and can lead to severe dehydration and even death if untreated. Unlike diabetes and hypertension, which are non-communicable diseases often influenced by lifestyle factors, HIV/AIDS and cholera are infectious diseases that can be transmitted from person to person.
3. Why might patients with periodontal disease require increased protein intake?
- A. Both the statement and the reason are correct and related
- B. Both the statement and the reason are correct but are not related
- C. The statement is correct, but the reason is not correct
- D. The statement is not correct, but the reason is correct
Correct answer: A
Rationale: Patients with periodontal disease may require increased protein intake due to the physiological response to inflammation and infection, which can negatively impact protein synthesis. Protein is essential for wound healing and tissue repair, and an infection can increase the body's protein requirements. Therefore, ensuring an adequate protein intake is particularly important for these patients. Choice A is correct because the statement and reason are both accurate and directly related to each other, supporting the increased protein needs in patients with periodontal disease. Choices B, C, and D are incorrect as they do not accurately assess the relationship between the statement and the reason provided in the question.
4. A nurse is planning eating strategies with a client who has nausea from equilibrium imbalance. Which of the following strategies should the nurse recommend?
- A. Encourage the client to eat even if nauseated.
- B. Provide low-fat carbohydrates with meals.
- C. Limit fluid intake between meals.
- D. Serve hot foods at mealtime.
Correct answer: B
Rationale: Providing low-fat carbohydrates with meals can help manage nausea without overloading the digestive system.
5. A patient is taking a statin for hyperlipidemia. What important instruction should the nurse provide to the patient?
- A. Take the medication at night to avoid muscle pain.
- B. Take the medication in the morning to ensure it works throughout the day.
- C. Avoid consuming alcohol while taking this medication.
- D. Take the medication with a high-fat meal to increase absorption.
Correct answer: A
Rationale: The correct answer is to instruct the patient to take the medication at night to avoid muscle pain. Statins are known to potentially cause muscle pain or weakness; taking the medication at night can help reduce the incidence of these side effects. Option B is incorrect because the timing of statin administration is not related to its effectiveness throughout the day. Option C is a general precaution when taking medications but not the most important instruction specific to statins. Option D is incorrect as taking the medication with a high-fat meal can actually decrease its absorption.
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