ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: D
Rationale: Inserting sterile packing into the nares is the safest option to prevent infection if the fluid is cerebrospinal fluid (CSF), indicating a possible basilar skull fracture, while avoiding actions that could introduce bacteria.
Question 2 of 5
A nurse reviewing a client's chart reads that the client was observed having a complex partial seizure with automatisms of the face. What does the nurse understand this to mean?
Correct Answer: D
Rationale: Complex partial seizures involve focal brain activity with impaired awareness, and automatisms like lip-smacking are involuntary facial movements (
Choice
D). Losing bladder control is typical of generalized tonic-clonic seizures (
Choice
A). Fixed, dilated eyes are not specific to complex partial seizures (
Choice
B). Involuntary groaning is less characteristic than facial automatisms (
Choice
C).
Question 3 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: C
Rationale: Reason: Inserting a nasal swab to observe the fluid is not recommended because it can potentially harm the patient. If the fluid draining from the nose is cerebrospinal fluid (CSF), which is a clear, colorless body fluid found in the brain and spinal cord, inserting a swab could introduce bacteria into this sterile environment. This could lead to serious complications such as meningitis, an inflammation of the membranes surrounding the brain and spinal cord. Reason: Suctioning the nose gently with a bulb syringe is also not recommended. Again, if the fluid is CSF, suctioning could potentially draw bacteria up into the nasal cavity and into the brain, leading to an increased risk of infection. Additionally, suctioning could potentially cause trauma to the nasal passages, leading to further complications. Reason: Allowing the drainage to drip onto a sterile gauze pad is the safest option. This method avoids the risk of introducing infection into the CSF and allows for the fluid to be tested to confirm if it is CSF. If the fluid is indeed CSF, this could indicate a basilar skull fracture, a serious injury that requires immediate medical attention. Reason: Inserting sterile packing into the nares is not recommended. While this might seem like a good way to stop the drainage, it could actually be very dangerous. If the fluid is CSF, the packing could act as a conduit, drawing bacteria up into the brain and leading to infection. Additionally, the packing could cause pressure on the brain if the fluid continues to drain but has nowhere to go.
Question 4 of 5
A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Changing the IV tubing every 24 hours is recommended to prevent infection and maintain sterility, as TPN can support bacterial growth (
Choice
C). Blood glucose should be monitored every 4-6 hours, not every 12 hours, due to TPN's high-glucose content affecting blood sugar levels (
Choice
A). IV site dressings should be changed daily or as needed to prevent infection, not every 4 days (
Choice
B). The client should be weighed daily, not every other day, to assess fluid balance and nutritional status (
Choice
D).
Question 5 of 5
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
Correct Answer: B
Rationale: Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis. Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease. Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy. Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.