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 fol

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. What dietary recommendations should be given to a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bed
C. Increase fluid intake during meals
D. Drink milk as a snack

Correct answer: A

Rationale: The correct dietary recommendation for a patient with GERD is to avoid mint and spicy foods. These foods can trigger symptoms of GERD and lead to acid reflux. Choice B is incorrect because eating large meals before bed can exacerbate GERD symptoms by increasing the likelihood of acid reflux during sleep. Choice C is incorrect as increasing fluid intake during meals can worsen GERD symptoms by distending the stomach, leading to increased pressure on the lower esophageal sphincter. Choice D is also incorrect because while milk may provide temporary relief for some individuals, it is not a recommended long-term solution for managing GERD.

3. What dietary teaching should be provided to a patient with pre-dialysis end-stage kidney disease?

A. Limit phosphorus intake to 700 mg/day
B. Increase protein intake to 1.5 g/kg/day
C. Restrict sodium intake to 1 g/day
D. Increase potassium intake to 3 g/day

Correct answer: A

Rationale: The correct answer is to limit phosphorus intake to 700 mg/day for a patient with pre-dialysis end-stage kidney disease. Excess phosphorus can lead to complications such as bone and heart issues in these patients. Increasing protein intake (Choice B) is generally not recommended as it can lead to increased waste production that the kidneys may struggle to eliminate. Restricting sodium intake (Choice C) is important for managing blood pressure, but the recommendation is usually higher than 1 g/day. Increasing potassium intake (Choice D) is not typically advised in patients with kidney disease, as they often need to limit potassium due to impaired kidney function.

4. What ECG changes are seen with hyperkalemia?

A. Flattened T waves
B. Elevated ST segments
C. Prominent U waves
D. Widened QRS complex

Correct answer: A

Rationale: Flattened T waves are an early ECG sign of hyperkalemia. Hyperkalemia affects the repolarization phase of the cardiac action potential, leading to changes such as peaked T waves, prolonged PR interval, widened QRS complex, and ultimately sine wave pattern. Elevated ST segments, prominent U waves, and widened QRS complex are not typically associated with hyperkalemia, making choices B, C, and D incorrect.

5. What are the early signs of hypokalemia on an ECG?

A. Flattened T waves
B. Elevated ST segments
C. Prominent U waves
D. Widened QRS complex

Correct answer: A

Rationale: Flattened T waves are an early sign of hypokalemia on an ECG. In hypokalemia, the T waves may flatten and eventually invert. Elevated ST segments are not typically associated with hypokalemia. Prominent U waves are seen in conditions like hypokalemia, but they are not considered an early sign. A widened QRS complex is more commonly associated with hyperkalemia rather than hypokalemia.