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ATI Capstone Medical Surgical Assessment 1 Quizlet
1. What are the signs and symptoms of Increased Intracranial Pressure (IICP)?
- A. Irritability, confusion, restlessness
- B. Fatigue and SOB
- C. Changes in pupillary response
- D. Elevated blood pressure
Correct answer: A
Rationale: The correct answer is A: Irritability, confusion, restlessness. These are common signs of Increased Intracranial Pressure (IICP) as they result from the increased pressure on brain tissue. Choices B, C, and D are incorrect. Fatigue and shortness of breath (SOB) are not typical symptoms of IICP. Changes in pupillary response can be seen in other conditions but are not specific to IICP. Elevated blood pressure is not a common sign of IICP.
2. What ECG change is associated with hyperkalemia?
- A. Flattened T waves
- B. ST depression
- C. Prominent U waves
- D. Elevated ST segments
Correct answer: B
Rationale: The correct ECG change associated with hyperkalemia is ST depression. Hyperkalemia typically presents with ECG changes such as peaked T waves, prolonged PR interval, widened QRS complex, and finally, ST segment depression. Flattened T waves are more commonly associated with hypokalemia. Prominent U waves are seen in hypokalemia as well. Elevated ST segments are not a typical ECG finding in hyperkalemia.
3. What should the nurse monitor for in a patient with hypokalemia?
- A. Monitor for muscle weakness
- B. Check deep tendon reflexes (DTRs)
- C. Monitor for seizures
- D. Monitor for bradycardia
Correct answer: A
Rationale: The correct answer is to monitor for muscle weakness in a patient with hypokalemia. Hypokalemia, which is low potassium levels, can lead to muscle weakness due to its effects on neuromuscular function. Checking deep tendon reflexes (Choice B) is not typically associated with hypokalemia. Seizures (Choice C) are more commonly associated with low calcium levels rather than low potassium levels. Bradycardia (Choice D) is a symptom of hyperkalemia (high potassium levels) rather than hypokalemia.
4. What intervention should the nurse take for a patient experiencing delayed wound healing?
- A. Monitor serum albumin levels
- B. Apply a dry dressing
- C. Administer antibiotics
- D. Change the wound dressing every 8 hours
Correct answer: A
Rationale: Monitoring serum albumin levels is crucial for patients with delayed wound healing. Low albumin levels indicate a lack of protein, which can impair the healing process and increase the risk of infection. By monitoring serum albumin levels, the nurse can assess the patient's nutritional status and make necessary interventions to promote wound healing. Applying a dry dressing (Choice B) may be appropriate depending on the wound characteristics, but it does not address the underlying cause of delayed healing. Administering antibiotics (Choice C) is not the first-line intervention for delayed wound healing unless there is an active infection present. Changing the wound dressing every 8 hours (Choice D) may lead to excessive disruption of the wound bed and hinder the healing process.
5. What should a healthcare professional monitor for in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and signs of infection
- D. Loss of deep tendon reflexes
Correct answer: A
Rationale: Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome. In this condition, increased pressure within a muscle compartment impairs blood flow, leading to severe pain that is not relieved by usual measures, pallor from decreased blood flow, and pulselessness due to compromised circulation. These signs indicate a medical emergency requiring immediate intervention. Localized redness and swelling (Choice B) are more characteristic of inflammation or infection rather than compartment syndrome. Fever and signs of infection (Choice C) are not typical manifestations of compartment syndrome. Loss of deep tendon reflexes (Choice D) is associated with conditions affecting the nervous system, not compartment syndrome.
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