Which physical assessment finding should be reported to the physician?

Questions 179

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ATI Detailed Answer Key Medical Surgical Questions

Question 1 of 5

Which physical assessment finding should be reported to the physician?

Correct Answer: C

Rationale: A bulging red or blue tympanic membrane indicates acute otitis media or other serious conditions requiring medical intervention.

Question 2 of 5

To improve Mr. Puff’s breathing pattern, the nurse can

Correct Answer: D

Rationale: Pursed-lip breathing improves oxygenation and reduces shortness of breath.

Question 3 of 5

Which statements are correct for lithium?

Correct Answer: C

Rationale: Lithium has a narrow therapeutic window, requiring careful monitoring to prevent toxicity.

Question 4 of 5

How should the nurse respond to Mrs. West’s statement, “Oh well, I have already lived my life anyway.”

Correct Answer: B

Rationale: Encouraging the patient to express feelings fosters trust and understanding.

Question 5 of 5

A client is scheduled for a pneumonectomy in the morning. The client has had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:

Correct Answer: A

Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.

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