ATI n300 Med Surg Exam

Question 1 of 5

The nurse is caring for an elderly client with type II diabetes who has had nausea, vomiting and diarrhea for several days and who now is disoriented and listless. Initial vital signs: B/P 72/62, pulse 146 irregular and thready, respirations 38 breaths per minute and shallow, and temperature of 97.0 F rectally. The skin is cool and clammy. The nurse recognizes that this client's symptoms are most indicative of which stage and type of shock? The:

A. initial stage of septic shock.B. refractory stage of obstructive shock.C. progressive stage of hypovolemic shock.D. compensatory stage of diabetic shock.

Correct Answer: C

Rationale: The client shows signs of hypovolemic shock from fluid loss, with progressive stage indicated by hypotension, tachycardia, and altered mental status.

Question 2 of 5

Complete the following sentence with one of the options regarding the pathophysiology of this type of shock. The nurse isp caring for an elderly patient from a nursing home diagnosed with a urinary tract infection. The nurse assesses the patient as hypotensive, tachycardic, febrile, tachypneic, and with an altered mental status. The nurse understands that the pathophysiology of this type of shock is caused by___

A. Massive blood loss leading to decreased oxygen delivery to tissuesB. Severe allergic reaction causing systemic vasodilation and increased capillary permeabilityC. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusionD. Cardiac failure resulting in inadequate tissue perfusion and oxygenation

Correct Answer: C

Rationale: The patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.

Question 3 of 5

The client presents with a complaint of 'always dropping things and falling down.' During the neurologic assessment, the nurse notices the client is unable to perform rapid alternating movements. Instead the client's response is very slow and misses often. What neurologic dysfunction would the nurse suspect?

A. inability to understand directionsB. Lesion of cranial nerve IXC. Dysfunction of the cerebellumD. Vestibular disease

Correct Answer: C

Rationale: The cerebellum controls coordination and fine motor movements. Inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.

Question 4 of 5

The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?

A. Notify the physician and anticipate the need for endotracheal intubationB. Place the client in semi-fowler's position and administer albuterol breathing treatmentC. Encourage the client to cough, take deep breaths, and then auscultate againD. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry

Correct Answer: A

Rationale: The absence of wheezes, decreased lung sounds, hoarseness, and gray sputum indicate progressive airway obstruction from inhalation injury, requiring immediate intubation.

Question 5 of 5

What action priority in preventing anaphylactic shock?

A. Removal of the educating patient to carry an EpipenB. Assess and document for previous allergies and drug reactions prior to medication administrationC. Administer diphenhydramine and solumedrol IV and solumedrol IV at the first sign of allergic symptomsD. Application of red allergy bracelet patient's upper extremity

Correct Answer: B

Rationale: Identifying and documenting allergies before administering medications or treatments helps prevent exposure to known allergens, reducing the risk of anaphylaxis.