ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?
Correct Answer: B
Rationale: Legal blindness is defined as a best-corrected visual acuity of 20/200 or worse in the better eye. Full vision loss in one eye, inability to see from 200 feet without lenses, or 20/60 impairment do not meet this criterion.
Question 2 of 5
A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?
Correct Answer: D
Rationale: Reason: This is incorrect because administering medications and electrolytes is not the primary purpose of inserting a nasogastric tube for a client with acute peritonitis. Medications and electrolytes can be given through other routes, such as IV or oral. Reason: This is incorrect because dilating the stomach as a presurgical preparation is not a relevant Reason for inserting a nasogastric tube for a client with acute peritonitis. Dilating the stomach may be done before some types of gastric surgery, but it does not apply to peritonitis. Reason: This is incorrect because stating that you will not be able to eat for several days is not an adequate explanation for inserting a nasogastric tube for a client with acute peritonitis. This statement does not address the rationale or the benefits of the procedure. It may also cause anxiety and resentment in the client. Reason: This is the correct choice because removing secretions and decompressing the stomach is the main Reason for inserting a nasogastric tube for a client with acute peritonitis. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can cause abdominal distension, pain, nausea, and vomiting. A nasogastric tube can suction out the gastric contents and reduce the pressure and irritation in the abdomen.
Question 3 of 5
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
Correct Answer: D
Rationale: Severe pain in the eye post-cataract surgery may indicate complications such as infection, inflammation, bleeding, or increased intraocular pressure, necessitating immediate reporting to the provider.
Question 4 of 5
A nurse is caring for a client who has a complete spinal cord injury. Based on the nurse's understanding about the degree of this type of injury, what can the nurse expect will be the client's level of function?
Correct Answer: A
Rationale: Reason: This is the correct choice because a complete spinal cord injury is a condition where there is no motor or sensory function below the level of injury. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. The client will also have impaired thermoregulation, breathing, and blood pressure. The client will need 24-hour a day care to assist with mobility, hygiene, elimination, nutrition, and prevention of complications. Reason: This is incorrect because a client who is able to assist with transfer and perform self-care has a partial spinal cord injury, not a complete one. A partial spinal cord injury is a condition where there is some motor or sensory function below the level of injury. The degree of impairment depends on the extent and location of the damage. Reason: This is incorrect because a client who is able to roll over independently has a lower spinal cord injury, not a complete one. A lower spinal cord injury is a condition where there is damage to the lumbar or sacral segments of the spinal cord. The client will have paralysis of the lower limbs (paraplegia) and some loss of bladder, bowel, and sexual function. The client will still have some control over the upper limbs and trunk. Reason: This is incorrect because a client who is able to drive an electric wheelchair has an upper spinal cord injury, not a complete one. An upper spinal cord injury is a condition where there is damage to the cervical or thoracic segments of the spinal cord. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. However, the client may still have some movement or sensation in the shoulders, arms, or hands.
Question 5 of 5
A client arrives to the clinic with reports of progressive weakness in his lower extremities. Which of the following findings in the client's history is consistent with the client developing Guillain-Barre syndrome?
Correct Answer: D
Rationale: Reason: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves. Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases. Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection. Reason: This is the correct answer because cytomegalovirus is one of the common infections that can trigger Guillain-Barre syndrome. It can cause inflammation and damage to the myelin sheath that covers the nerves.