ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?
- A. Eat three large meals daily
- B. Consume high-calorie foods
- C. Limit caffeinated drinks to two per day
- D. Drink fluids during meal time
Correct answer: B
Rationale: The correct answer is B: 'Consume high-calorie foods.' Clients with COPD often have increased energy needs due to the work of breathing. Consuming high-calorie, high-protein foods can help provide the necessary energy and prevent weight loss. Choice A is incorrect because eating three large meals daily may lead to increased shortness of breath due to a full stomach putting pressure on the diaphragm. Choice C is incorrect because caffeinated drinks can contribute to dehydration, which is not ideal for clients with COPD. Choice D is incorrect because drinking fluids during mealtime can cause bloating and early satiety, making it difficult for clients to consume enough calories.
2. A parent of a child with celiac disease is receiving teaching from a nurse. Which of the following statements should the nurse make?
- A. You should give your child vitamin supplements that contain iron.
- B. Your child will need a gluten-free diet.
- C. Your child should consume large amounts of dietary fiber.
- D. Your child can resume eating whole wheat bread.
Correct answer: B
Rationale: The correct answer is B. Celiac disease requires a strict gluten-free diet to manage the condition effectively. Gluten-containing foods like wheat, barley, and rye must be avoided to prevent intestinal damage and symptoms in individuals with celiac disease. Therefore, the nurse should emphasize the importance of a gluten-free diet to the parent of the child with celiac disease.
3. Rhabdomyolysis can result in serious complications. In addition to muscle pain and weakness, a patient will complain of:
- A. paresthesias.
- B. bone pain.
- C. dark urine.
- D. diarrhea.
Correct answer: C
Rationale: Dark urine is a classic symptom of rhabdomyolysis. When muscle breakdown occurs, myoglobin is released into the bloodstream and filtered by the kidneys, leading to dark urine. Paresthesias (choice A) refer to abnormal sensations like tingling or numbness and are not typically associated with rhabdomyolysis. Bone pain (choice B) is not a prominent symptom of rhabdomyolysis. Diarrhea (choice D) is not a common complaint in rhabdomyolysis cases and is not directly related to muscle breakdown.
4. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following actions should the nurse take?
- A. Administer naloxone
- B. Administer diazepam
- C. Encourage oral fluid intake
- D. Administer magnesium sulfate
Correct answer: B
Rationale: The correct action for the nurse to take when caring for a client with alcohol use disorder experiencing withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to manage withdrawal symptoms in these clients by reducing anxiety, tremors, and the risk of seizures. Administering naloxone (Choice A) is used for opioid overdose, not alcohol withdrawal. Encouraging oral fluid intake (Choice C) is generally beneficial but not a specific intervention for alcohol withdrawal. Administering magnesium sulfate (Choice D) is not indicated for alcohol withdrawal but may be used for other conditions like preeclampsia or eclampsia.
5. A 20-year-old male shoots his hand with a nail gun while replacing roofing shingles. Which of the following cell types would be the first to aid in killing bacteria to prevent infection in his hand?
- A. Eosinophils
- B. Neutrophils
- C. Leukotrienes
- D. Monocytes
Correct answer: B
Rationale: Neutrophils are the first responders to bacterial infections. When there is a breach in the skin like in this scenario, neutrophils are quickly recruited to the site of injury to phagocytize and kill bacteria. Eosinophils are primarily involved in parasitic infections and allergic reactions, making choice A incorrect. Leukotrienes are lipid mediators involved in inflammation but are not cells, so choice C is incorrect. Monocytes are precursors to macrophages and play a role in immune response, but they are not the first cells to arrive at the site of a bacterial infection, making choice D incorrect.
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