ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. A nurse is planning care for a patient diagnosed with diabetes insipidus. What should be included in the care plan?
- A. Monitor serum albumin levels
- B. Restrict protein intake to 0.55-0.60 g/kg/day
- C. Encourage the patient to increase fluid intake
- D. Teach the patient to avoid alcohol
Correct answer: A
Rationale: The correct answer is to monitor serum albumin levels. In patients with diabetes insipidus, monitoring serum albumin levels is essential to assess for dehydration and nutritional deficits. Choices B, C, and D are not directly related to managing diabetes insipidus. Restricting protein intake, encouraging fluid intake, and teaching the patient to avoid alcohol are interventions that may be relevant for other medical conditions but are not specific to addressing the needs of a patient with diabetes insipidus.
2. A client asks the nurse to explain the difference between stable and unstable angina. What is the best response by the nurse?
- A. “Stable angina is predictable in its frequency, intensity, and duration. Unstable angina is when angina episodes become more frequent or severe, and occur during periods of rest.”
- B. “Unstable angina is caused by spasms of the coronary arteries. Stable angina is when angina episodes become more frequent or severe, and occur during periods of rest.”
- C. “Unstable angina is predictable in its frequency, intensity, and duration. Stable angina is when angina episodes become more frequent or severe, and occur during periods of rest.”
- D. “Stable angina is caused by spasms of the coronary arteries. Unstable angina is when angina episodes become more frequent or severe, and occur during periods of rest.”
Correct answer: “Stable angina is predictable in its frequency, intensity, and duration. Unstable angina is when angina episodes become more frequent or severe, and occur during periods of rest.”
Rationale: Stable angina is typically triggered by physical exertion or emotional stress and is predictable in its frequency, intensity, and duration. In contrast, unstable angina is characterized by angina episodes that are unexpected, more severe, prolonged, and can occur at rest. Understanding these differences can help healthcare providers assess and manage angina episodes effectively, ensuring appropriate interventions are implemented promptly based on the type of angina present.
3. A nurse is planning to teach a client about a low-potassium diet. Which of the following foods should the nurse instruct the client to avoid?
- A. Butter
- B. Poultry
- C. Yogurt
- D. Orange juice
Correct answer: D: Orange juice
Rationale: Orange juice is high in potassium and should be avoided in a low-potassium diet. Butter, poultry, and yogurt are low-potassium food choices and can be included in a low-potassium diet. Poultry is a good source of lean protein, yogurt is a good source of calcium and protein, and butter is low in potassium. Therefore, the nurse should instruct the client to avoid orange juice as it is high in potassium, which is not suitable for a low-potassium diet.
4. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
- A. Yellow-tinged sclerae
- B. Shiny, smooth tongue
- C. Numbness of the extremities
- D. Gum bleeding and tenderness
Correct answer: C
Rationale: The correct answer is C: Numbness of the extremities. Numbness of the extremities is a common finding in patients with pernicious anemia, which is caused by cobalamin (vitamin B12) deficiency. This deficiency affects the peripheral nervous system, leading to neurological symptoms like numbness and tingling in the extremities. Choices A, B, and D are incorrect: Yellow-tinged sclerae is more indicative of jaundice or liver dysfunction, a shiny smooth tongue is seen in conditions like glossitis, and gum bleeding and tenderness are associated with periodontal disease or vitamin C deficiency, not pernicious anemia.
5. A client who is breastfeeding is being taught diet modification by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should drink an 8-ounce glass of water each time my baby nurses.
- B. I should take a 1500-milligram iron supplement daily.
- C. I can eat a 2500-calorie daily diet to lose 1 lb per week.
- D. I can eat ounces of swordfish daily.
Correct answer: A
Rationale: The correct answer is A because drinking an 8-ounce glass of water each time the baby nurses helps maintain hydration and support milk production. Choice B is incorrect as the need for iron supplementation should be discussed with a healthcare provider. Choice C is incorrect as a 2500-calorie diet is not typically recommended for weight loss during breastfeeding. Choice D is incorrect as consuming high levels of swordfish is not advisable due to its mercury content, which can be harmful to the baby.
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