ATI Capstone Adult Medical Surgical Assessment 2

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.

Correct Answer: A

Rationale: The correct answer is A: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These signs indicate that the brain is starting to experience pressure, often due to conditions such as trauma, tumors, or hemorrhage. Sudden onset of seizures (choice B) is not typically an early sign of IICP but can occur later as the pressure increases. Decreased heart rate and pupillary response (choice C) are more indicative of late-stage IICP as the brainstem becomes compromised. Loss of consciousness (choice D) is a late sign of IICP when the pressure has significantly increased and is causing significant brain dysfunction.

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.

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.

Correct Answer: A

Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on a misread glucose level, which could lead to hypoglycemia due to excessive insulin action lowering blood glucose levels. Monitoring for hypoglycemia allows for prompt recognition and intervention if blood glucose levels drop significantly. Choice B, monitoring for hyperkalemia, is incorrect as administering insulin would not cause hyperkalemia. Choice C, administering glucose IV, is not appropriate at this time since the patient's blood glucose level is already elevated. Choice D, documenting the incident, is important but not the priority at this moment when patient safety is at risk due to potential hypoglycemia.