ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What dietary recommendation should be given to a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bedtime
- C. Consume liquids with meals
- D. Eat three large meals per day
Correct answer: A
Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. Mint and spicy foods can aggravate GERD symptoms by relaxing the lower esophageal sphincter and increasing stomach acid production, leading to acid reflux. Choices B, C, and D are incorrect. Eating large meals before bedtime can worsen GERD symptoms as lying down can promote acid reflux. Consuming liquids with meals can also exacerbate GERD by increasing stomach distension and pressure on the lower esophageal sphincter. Eating three large meals per day can overload the stomach and trigger acid reflux episodes in patients with GERD.
2. During an escharotomy on a patient with a burn injury, what is the purpose of this procedure?
- A. To release pressure and improve circulation in the affected area
- B. To remove dead tissue from the burn area
- C. To improve breathing by reducing skin tightness
- D. To prevent infection in the burned area
Correct answer: A
Rationale: Corrected Question: During an escharotomy on a patient with a burn injury, the purpose of this procedure is to release pressure and improve circulation in the affected area. This intervention is crucial in severe burns where the formation of eschar (dead tissue) can lead to increased pressure, compromising circulation and potentially causing further tissue damage. Choices B, C, and D are incorrect because escharotomy specifically aims to address pressure and circulation issues in severe burn injuries, rather than removing dead tissue, improving breathing, or preventing infection.
3. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?
- A. Lie on your left side.
- B. Lie on your right side.
- C. Increase your fluid intake.
- D. Decrease your fluid intake.
Correct answer: B
Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.
4. What are the signs and symptoms of a hemorrhagic stroke?
- A. Sudden severe headache, decreased level of consciousness, and seizures
- B. Loss of consciousness and weakness
- C. Temporary vision loss
- D. Severe chest pain and shortness of breath
Correct answer: A
Rationale: The correct answer is A. A hemorrhagic stroke often presents with a sudden severe headache, decreased level of consciousness, and seizures due to bleeding in the brain. Choice B, loss of consciousness and weakness, is more indicative of an ischemic stroke where a clot blocks blood flow to the brain. Choice C, temporary vision loss, is more commonly seen in conditions like transient ischemic attacks (TIAs) or retinal migraines. Choice D, severe chest pain and shortness of breath, are symptoms more associated with cardiac issues like a heart attack.
5. A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?
- A. Lower the height of the solution container
- B. Increase the flow of enema solution
- C. Remove the enema tubing
- D. Stop the procedure
Correct answer: A
Rationale: The correct action to relieve abdominal cramping after enema administration is to lower the height of the solution container. This adjustment slows down the flow rate of the enema solution, which can help reduce discomfort by decreasing the pressure on the patient's abdomen. Increasing the flow of the enema solution (Choice B) would exacerbate the cramping by introducing more solution quickly. Removing the enema tubing (Choice C) is not necessary to address the cramping, and stopping the procedure (Choice D) may not be needed if adjusting the height of the solution container can resolve the issue.
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