ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A client with red scaling papules on his elbows, knees, lower back, and scalp arrives to the clinic. Which of the following questions will the nurse include in her assessment?
Correct Answer: A
Rationale: Asking if the lesions hurt helps assess pain and discomfort associated with psoriasis, which is indicated by red scaling papules.
Question 2 of 5
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?
Correct Answer: B
Rationale: Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed. Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention. Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing. Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.
Question 3 of 5
A nurse is assessing a client who has suffered a traumatic brain injury. When the nurse applies a stimuli to the client, which of the following responses by the client indicates that the client has suffered an extensive cervical spine injury?
Correct Answer: D
Rationale: Decerebrate positioning, characterized by extension and outward rotation of limbs, indicates severe brainstem or upper cervical spine injury, affecting vital functions.
Question 4 of 5
A client receiving parenteral nutrition by central venous access reports feeling unwell. The nurse assesses the client and suspects that the central line has become infected. Which of the following findings indicate that the client has developed a systemic infection? Select all that apply.
Correct Answer: B,E,F
Rationale: Purulent drainage, leukocytosis, and fever indicate a systemic infection, as they reflect bacterial invasion and immune response spreading beyond the local site.
Question 5 of 5
When assessing a client diagnosed with basal cell carcinoma, which of the following findings will the nurse expect?
Correct Answer: C
Rationale: Basal cell carcinoma typically presents as a small, scaly, dry lesion that may bleed or crust, often in sun-exposed areas like the elbow.