ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What dietary changes should a patient with GERD make to manage their symptoms?
- A. Avoid mint and spicy foods
- B. Eat large, frequent meals
- C. Consume liquids with meals
- D. Eat small, frequent meals
Correct answer: A
Rationale: The correct answer is A: Avoid mint and spicy foods. Patients with GERD should avoid foods like mint and spicy dishes as they can trigger symptoms by increasing gastric acid secretion. Choices B, C, and D are incorrect. Eating large, frequent meals can exacerbate GERD symptoms by putting more pressure on the lower esophageal sphincter, consuming liquids with meals can lead to increased reflux, and eating small, frequent meals is the recommended approach to reduce symptoms and manage GERD.
2. 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.
3. What is the primary concern for a patient with a CD4 T-cell count below 180 cells/mm³?
- A. Increased risk of severe infection
- B. Increased risk of anemia
- C. Increased risk of bleeding
- D. Increased risk of dehydration
Correct answer: A
Rationale: A CD4 T-cell count below 180 cells/mm³ indicates a severely immunocompromised state, leading to an increased risk of severe infection. In individuals with low CD4 counts, the immune system is significantly weakened, making them more susceptible to opportunistic infections. Anemia (choice B), bleeding (choice C), and dehydration (choice D) are not the primary concerns associated with a low CD4 T-cell count. While these conditions may occur as secondary effects or complications, the primary focus is on preventing and managing severe infections in patients with severely compromised immune systems.
4. What is the first nursing action for a patient with chest pain and possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Increase fluids to prevent dehydration
- C. Obtain cardiac enzymes
- D. Get IV access and auscultate heart sounds
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the priority nursing action for a patient with chest pain and possible acute coronary syndrome. Nitroglycerin helps dilate the blood vessels, improve blood flow to the heart, and reduce cardiac workload. This action aims to relieve chest pain promptly and prevent further cardiac tissue damage. Increasing fluids is not the initial priority for a patient with chest pain and possible acute coronary syndrome. Obtaining cardiac enzymes is important for diagnosis but is not the first action in managing acute symptoms. Getting IV access and auscultating heart sounds are important interventions, but they come after administering sublingual nitroglycerin in the management of acute coronary syndrome.
5. What are the expected symptoms in a patient with a thrombotic stroke?
- A. Gradual loss of function on one side of the body
- B. Sudden loss of consciousness
- C. Severe headache and confusion
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: A thrombotic stroke typically presents with a gradual loss of function on one side of the body. This gradual onset distinguishes it from a hemorrhagic stroke, which often manifests with sudden and severe symptoms like loss of consciousness (choice B), severe headache and confusion (choice C), or loss of sensation in the affected limb (choice D). Therefore, choices B, C, and D are not typically associated with thrombotic strokes.
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