ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?
Correct Answer: B
Rationale: Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue. Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord. Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time. Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.
Question 2 of 5
A nurse at an ophthalmology clinic is providing medication teaching to a client who has open angle glaucoma. Which of the following instructions should the nurse provide?
Correct Answer: D
Rationale: Open angle glaucoma requires lifelong medication to maintain normal intraocular pressure and prevent vision loss.
Question 3 of 5
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Correct Answer: D
Rationale: Fluid and electrolyte imbalance is a common complication of ileostomy surgery because the colon, which is bypassed, is primarily responsible for absorbing fluids and electrolytes. This leads to increased loss through stool, potentially causing dehydration and imbalances in sodium and potassium.
Question 4 of 5
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client reports a sudden increase in abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the best first action the nurse should take?
Correct Answer: C
Rationale: Notifying the healthcare provider is critical as these symptoms suggest a perforated appendix, a life-threatening condition requiring immediate intervention.
Question 5 of 5
A blind client reports that they are having difficulty with sleep that is affecting their daytime activities. Which of the following will the nurse include in her plan of care for the client?
Correct Answer: D
Rationale: Reason: This is incorrect because a referral to a sleep study program is not the most appropriate plan of care for a blind client who has difficulty with sleep. A sleep study program is used to diagnose and treat sleep disorders such as sleep apnea, narcolepsy, or restless legs syndrome. Reason: This is incorrect because assisting the client to see if a night shift job is available is not a helpful plan of care for a blind client who has difficulty with sleep. A night shift job can disrupt the circadian rhythm and worsen the sleep quality and quantity of the client. Reason: This is incorrect because institution of opioids and sedatives is not a safe plan of care for a blind client who has difficulty with sleep. Opioids and sedatives can cause addiction, dependence, tolerance, and withdrawal symptoms. They can also impair the respiratory and cognitive functions of the client. Reason: This is the correct choice because education about non-24 disorder is an essential plan of care for a blind client who has difficulty with sleep. Non-24 disorder is a condition where the internal clock of the body does not synchronize with the 24-hour day-night cycle. It can cause irregular sleep patterns, daytime fatigue, and mood disturbances. It is more common in blind people who lack light perception. The nurse should educate the client about the causes, symptoms, and treatments of non-24 disorder.