ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What are the adverse effects of radiation after a mastectomy?
- A. S3 heart sound, fatigue
- B. Pulselessness in the affected extremity
- C. SOB and JVD
- D. Localized pain, swelling, erythema
Correct answer: A
Rationale: The correct answer is A: S3 heart sound, fatigue. Radiation after a mastectomy can lead to fatigue and symptoms of heart failure, such as the presence of an S3 heart sound. Choices B, C, and D are incorrect. Pulselessness in the affected extremity would be more relevant to vascular complications, shortness of breath (SOB) and jugular venous distention (JVD) could indicate cardiac or respiratory issues unrelated to radiation, and localized pain, swelling, and erythema are more characteristic of a local inflammatory response rather than the systemic effects of radiation post-mastectomy.
2. A client is being taught by a nurse about adding more fiber to the diet. Which of the following foods has the highest fiber content?
- A. 1 cup cooked sweet potato
- B. 1 slice rye toast
- C. 1 cup raw watermelon
- D. 1 oz cashews
Correct answer: D
Rationale: The correct answer is D, 1 oz of cashews. Cashews have a higher fiber content compared to sweet potato, rye toast, and watermelon. While sweet potatoes and rye toast contain fiber, cashews have a higher concentration, making them a better choice for increasing fiber intake. Watermelon, on the other hand, is low in fiber compared to the other options provided.
3. Is the loss of teeth or supporting periodontium often associated with poor food selection and limited chewing ability, and do the patients' masticatory efficiency and biting force decline with each tooth lost?
- A. Both statements are true
- B. Both statements are false
- C. The first statement is true; the second is false
- D. The first statement is false; the second is true
Correct answer: A
Rationale: Both statements are indeed true. The loss of teeth or supporting periodontium frequently leads to poor food selection and limited chewing ability, as these conditions can make certain foods difficult to consume. Additionally, a patient's masticatory efficiency and biting force do decline with each tooth lost, as there are fewer teeth to distribute the force of the bite. Choices B, C, and D are incorrect because they suggest that one or both of these statements are false, which is not the case.
4. A nurse is planning a staff education program to review nursing interventions for clients who have kidney failure. Which of the following sources should the nurse identify as the best resource for obtaining evidence-based information?
- A. The advice of an expert nephrology nurse
- B. Retrospective chart reviews
- C. Facility critical pathway
- D. A recent peer-reviewed nursing research article
Correct answer: D
Rationale: A peer-reviewed nursing research article is the best resource for obtaining evidence-based information because it provides the most current and reliable data on nursing interventions. Choice A, the advice of an expert nephrology nurse, may be helpful but could be based on individual experience rather than the latest research. Retrospective chart reviews (Choice B) focus on past cases and may not reflect current best practices. Facility critical pathways (Choice C) offer standardized care plans but may not always incorporate the most up-to-date evidence-based practices.
5. The nurse is assessing a child suspected of having pinworms. Which is the most common symptom the nurse expects to assess?
- A. Restlessness
- B. Distractibility
- C. Rectal discharge
- D. Intense perianal itching
Correct answer: D
Rationale: Intense perianal itching is the most common symptom of pinworm infection, especially at night when the female worms lay their eggs
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