ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What are the expected signs of increased intracranial pressure (IICP)?
- A. Restlessness, confusion, irritability
- B. Severe headache and confusion
- C. Elevated blood pressure and bradycardia
- D. Bradycardia and altered pupil response
Correct answer: A
Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.
2. When caring for a patient with hypokalemia, what should the nurse monitor for?
- A. Monitor for muscle weakness
- B. Check for cardiac dysrhythmias
- C. Monitor for bradycardia
- D. Monitor for seizures
Correct answer: A
Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.
3. What is the first-line treatment for a patient experiencing wheezing and coughing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Methylprednisolone 100 mg IV
- C. Cromolyn 20 mg via nebulizer
- D. Aminophylline 500 mg IV
Correct answer: A
Rationale: The correct answer is A: Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction as it quickly opens the airways, providing rapid relief. Choice B, Methylprednisolone 100 mg IV, is a systemic corticosteroid that may be used in severe cases to reduce inflammation but is not the initial treatment for acute wheezing. Choice C, Cromolyn 20 mg via nebulizer, is a mast cell stabilizer that is more commonly used for prophylaxis rather than acute relief in allergic conditions. Choice D, Aminophylline 500 mg IV, is a bronchodilator that is less commonly used now due to its narrow therapeutic window and potential for toxicity, making it less preferred than Albuterol for initial treatment of wheezing.
4. What should a healthcare professional monitor in a patient receiving insulin who is at risk for hypoglycemia?
- A. Monitor blood glucose levels
- B. Monitor for respiratory distress
- C. Monitor for muscle weakness
- D. Monitor for hyperkalemia
Correct answer: A
Rationale: Monitoring blood glucose levels is crucial in patients receiving insulin who are at risk for hypoglycemia. Insulin can lower blood sugar levels, potentially leading to hypoglycemia, which can be harmful if not promptly recognized and managed. Checking blood glucose levels allows for early detection of low blood sugar levels, enabling timely interventions to prevent complications. Choices B, C, and D are incorrect as they do not directly relate to monitoring for hypoglycemia in patients receiving insulin.
5. 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.
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