what should be done if a patient experiences abdominal cramping during enema administration

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. What should be done if a patient experiences abdominal cramping during enema administration?

A. Lower the height of the enema solution container
B. Stop the procedure and remove the tubing
C. Continue the enema at a slower rate
D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the appropriate action is to lower the height of the enema solution container. This adjustment helps alleviate the cramping by reducing the pressure of the solution entering the colon. Stopping the procedure and removing the tubing (Choice B) is not necessary unless there are other complications. Continuing the enema at a slower rate (Choice C) may not address the immediate discomfort caused by cramping. Increasing the flow of the enema solution (Choice D) can exacerbate the cramping and should be avoided.

2. What are the expected ECG changes in hypokalemia?

A. Flattened T waves
B. ST elevation
C. Wide QRS complex
D. Tall T waves

Correct answer: A

Rationale: Flattened T waves are the most common ECG change seen in patients with hypokalemia. Hypokalemia leads to a decrease in serum potassium levels, affecting the repolarization phase of the cardiac action potential. This results in T wave flattening or inversion. ST elevation is typically seen in conditions like myocardial infarction, not in hypokalemia. Wide QRS complex is more associated with hyperkalemia than hypokalemia. Tall T waves are often seen in hyperkalemia, not hypokalemia.

3. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

A. It is okay to not want to touch the burned areas of your body.
B. Cosmetic surgery should be performed within the next year to be effective.
C. Reconstructive surgery can completely restore your previous appearance.
D. It could be helpful for you to attend a support group for people who have burn injuries.

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.

4. What symptoms are associated with a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Loss of motor function with nausea
D. Severe headache and vomiting

Correct answer: A

Rationale: A thrombotic stroke presents with a gradual loss of function on one side of the body due to a clot blocking blood flow to the brain. This gradual onset distinguishes it from a hemorrhagic stroke with sudden symptoms like loss of consciousness (Choice B), and from other conditions like migraine, which may present with severe headache and vomiting (Choice D). Nausea (Choice C) is not typically a primary symptom associated with a thrombotic stroke.

5. A nurse is planning care for a patient diagnosed with diabetes insipidus. What should be included in the care plan?

A. Monitor serum albumin levels
B. Restrict protein intake to 0.55-0.60 g/kg/day
C. Encourage the patient to increase fluid intake
D. Teach the patient to avoid alcohol

Correct answer: A

Rationale: The correct answer is to monitor serum albumin levels. In patients with diabetes insipidus, monitoring serum albumin levels is essential to assess for dehydration and nutritional deficits. Choices B, C, and D are not directly related to managing diabetes insipidus. Restricting protein intake, encouraging fluid intake, and teaching the patient to avoid alcohol are interventions that may be relevant for other medical conditions but are not specific to addressing the needs of a patient with diabetes insipidus.