ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What are the early signs of compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and infection
- D. Loss of sensation in the affected area
Correct answer: A
Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These signs are typical early indicators of compartment syndrome, suggesting compromised circulation. Choice B, localized redness and swelling, can be seen in conditions like cellulitis but are not specific to compartment syndrome. Choice C, fever and infection, are not characteristic early signs of compartment syndrome. Choice D, loss of sensation in the affected area, is more indicative of nerve damage rather than being one of the early signs of compartment syndrome.
2. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check the patient's cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow to the heart, which is crucial in managing acute coronary syndrome. While obtaining IV access and checking cardiac enzymes are important steps in the assessment and management of acute coronary syndrome, administering nitroglycerin takes precedence to alleviate symptoms and reduce cardiac tissue damage. Administering aspirin is also essential in the treatment of acute coronary syndrome, but it is not the immediate priority in this scenario.
3. What recommendations should the nurse provide to a patient diagnosed with GERD?
- A. Avoid items like mint that increase gastric acid secretion
- B. Eat small, frequent meals
- C. Avoid eating 1 hour before bedtime
- D. Avoid black and red pepper
Correct answer: A
Rationale: The correct answer is A: 'Avoid items like mint that increase gastric acid secretion.' Mint can relax the lower esophageal sphincter, leading to increased gastric acid secretion and worsening GERD symptoms. Choice B is a good recommendation for GERD management as it helps prevent excessive stomach distension. Choice C is also a recommended practice to avoid reflux during sleep. Choice D, avoiding black and red pepper, is not directly linked to exacerbating GERD symptoms, so it is not the most relevant recommendation for a patient diagnosed with GERD.
4. What should a healthcare provider monitor for in a patient with HIV and a CD4 T-cell count below 180 cells/mm3?
- A. Monitor for signs of infection
- B. Monitor for anemia
- C. Monitor for dehydration
- D. Monitor for bleeding
Correct answer: A
Rationale: A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise in a patient with HIV. Monitoring for signs of infection is crucial because the patient is at high risk of developing opportunistic infections. Anemia (choice B), dehydration (choice C), and bleeding (choice D) are not directly associated with a low CD4 T-cell count in patients with HIV.
5. What are the expected symptoms in a patient experiencing a thrombotic stroke?
- A. Gradual loss of function on one side of the body
- B. Sudden loss of consciousness
- C. Seizures and convulsions
- D. Severe headache and vomiting
Correct answer: A
Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' Thrombotic strokes typically result in a gradual onset of symptoms due to a blockage in a blood vessel in the brain, leading to a slow progression of neurological deficits. Choices B, C, and D are incorrect because sudden loss of consciousness, seizures, convulsions, severe headache, and vomiting are more commonly associated with other types of strokes or medical conditions, such as hemorrhagic strokes, epilepsy, or migraines.
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