ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is the expected finding in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and redness
- C. Numbness and tingling
- D. Fever and infection
Correct answer: A
Rationale: In a patient with compartment syndrome, the expected finding includes unrelieved pain, pallor, and pulselessness. These are classic signs of compartment syndrome and indicate compromised blood flow and tissue perfusion, necessitating urgent intervention. Choices B, C, and D are incorrect because localized swelling and redness, numbness and tingling, as well as fever and infection, are not typical findings associated with compartment syndrome.
2. A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
- A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
- B. Observe an area of redness on the breast of a client who is 1 day postpartum.
- C. Monitor vital signs during admission of a client who has gestational hypertension.
- D. Change the perineal pad of a client who just transferred from labor and delivery.
Correct answer: Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.
3. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?
- A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
- B. Advance the stronger leg and the cane together to support the weaker leg
- C. Remove the rubber tip when using the cane
- D. Hold the cane on the right side to provide support for the weaker leg
Correct answer: D
Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.
4. Which of the following is true about subjective distress?
- A. All individuals with mental illness experience some degree of distress
- B. Distress is the only criterion in diagnosing abnormality
- C. Its presence is enough for a clinician to determine if someone has a mental illness
- D. Some individuals with a mental disorder may not experience subjective distress
Correct answer: D
Rationale: Subjective distress is not universal among individuals with a mental disorder. Choice A is incorrect as not all individuals with mental illness experience distress. Choice B is incorrect because distress is just one of the criteria used in diagnosing abnormality, not the only one. Choice C is incorrect because the presence of subjective distress alone is not sufficient for a clinician to determine if someone has a mental illness.
5. A registered nurse (RN) administered a patient�s morning insulin as the breakfast tray arrived at 0800. The RN performed a complete assessment at the same time. Then, the RN got busy with her other patients and did not check on the patient until 1400. At that time, she found the patient unresponsive with a blood glucose of 23. Both the breakfast and lunch tray were at the bedside untouched. Which of the following could the RN be charged with?
- A. Quasi-intentional tort
- B. Misdemeanor
- C. Negligence
- D. Juvenile offense
Correct answer: C
Rationale: Negligence is the failure to act in a reasonable, ordinary, and prudent manner, causing harm to someone who is owed the duty to care.
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