a patient with severe pain and leg swelling is admitted what should the nurse assess for a patient with severe pain and leg swelling is admitted what should the nurse assess for
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?

Correct answer: B

Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.

2. In order to establish a therapeutic relationship with the client, the nurse must first have:

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?

Correct answer: B

Rationale: The correct answer is B: 'Use pursed-lip breathing during activities.' Pursed-lip breathing improves oxygenation by keeping airways open longer, facilitating better exhalation of carbon dioxide. Choice A is incorrect because avoiding physical activity can lead to deconditioning and worsen oxygenation. Choice C is irrelevant to improving oxygenation in COPD. Choice D is not directly related to improving oxygenation in COPD; weight-bearing exercises are important for bone health but not for oxygenation.

4. Maintaining a stable internal environment typically requires

Correct answer: negative feedback mechanisms.

Rationale: The correct answer is 'negative feedback mechanisms.' In biological systems, negative feedback mechanisms help maintain homeostasis by counteracting any deviations from the set point. They work to stabilize internal conditions and keep them within a narrow range. On the other hand, positive feedback mechanisms amplify changes and are not involved in maintaining stability. Choice B, 'an unstable outside environment,' is incorrect as internal stability is independent of external conditions like weather. Choice C, 'decreased atmospheric pressure,' is also incorrect as it does not directly relate to internal homeostasis.

5. How did philosopher John Locke characterize the mind of a child?

Correct answer: D

Rationale: Philosopher John Locke characterized the mind of a child as a 'blank slate,' indicating that it is devoid of innate ideas or characteristics. This concept suggests that a child's mind is shaped and developed through experiences and learning rather than having inherent qualities. Choices A, B, and C are incorrect as Locke did not view the mind of a child as innately good, conscientious, or associated with the superego-ideal. Instead, he believed that individuals are born without built-in mental content, emphasizing the importance of environmental influences on cognitive development.

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