ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What are the early signs of increased intracranial pressure (IICP)?
- A. Restlessness, irritability, and confusion
- B. Sudden onset of seizures
- C. Decreased heart rate and pupillary response
- D. Loss of consciousness
Correct answer: A
Rationale: The correct answer is A: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These signs indicate that the brain is starting to experience pressure, often due to conditions such as trauma, tumors, or hemorrhage. Sudden onset of seizures (choice B) is not typically an early sign of IICP but can occur later as the pressure increases. Decreased heart rate and pupillary response (choice C) are more indicative of late-stage IICP as the brainstem becomes compromised. Loss of consciousness (choice D) is a late sign of IICP when the pressure has significantly increased and is causing significant brain dysfunction.
2. A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?
- A. This medication can cause your urine to turn a dark color.
- B. Expect immediate relief after taking this medication.
- C. Take the medication with a high protein food.
- D. Skip a dose of the medication if you experience dizziness.
Correct answer: A
Rationale: The correct instruction to include in the teaching is that carbidopa/levodopa can cause the client's urine to turn a dark color, which is a harmless effect. It is crucial for the nurse to educate the client about this common side effect. Choice B is incorrect because immediate relief is not expected; therapeutic effects may take weeks to months. Choice C is incorrect as carbidopa/levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect as the client should not skip doses without consulting their healthcare provider, even if they experience dizziness.
3. What is the priority action for a patient with chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Check the patient's cardiac enzymes
- C. Administer aspirin
- D. Obtain IV access
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps dilate the blood vessels, reducing the workload of the heart and improving blood flow to the heart muscle, which is crucial in the management of acute coronary syndrome. Checking cardiac enzymes (choice B) is important for diagnosing a heart attack but is not the priority over providing immediate relief to the patient's chest pain. Administering aspirin (choice C) is also important in acute coronary syndrome to prevent further clot formation, but it is not the priority action for immediate pain relief. Obtaining IV access (choice D) is necessary for administering medications or fluids; however, in this scenario, providing sublingual nitroglycerin for prompt pain relief takes precedence.
4. A healthcare provider is assessing a client who reports a possible exposure to HIV. Which of the following findings should the healthcare provider identify as an early manifestation of HIV infection?
- A. Stomatitis
- B. Fatigue
- C. Wasting syndrome
- D. Lipodystrophy
Correct answer: B
Rationale: The correct answer is 'B: Fatigue.' Early manifestations of HIV infection often include symptoms like fatigue, fever, and rash, which are typical of viral infections. Stomatitis (choice A) refers to inflammation of the mouth and lips, which can occur in HIV but is not specific to early infection. Wasting syndrome (choice C) and lipodystrophy (choice D) are more commonly associated with later stages of HIV infection rather than early manifestations.
5. A patient who received an enema reports abdominal cramping. What should the nurse do?
- A. Increase the flow of the enema solution
- B. Lower the height of the enema solution container
- C. Remove the enema tubing
- D. Stop the procedure
Correct answer: B
Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.
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