ATI RN
ATI RN Medical Surgical 2023 Questions
Extract:
Question 1 of 5
A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?
Correct Answer: A
Rationale: Nuchal rigidity (neck stiffness) is a key sign of meningitis due to meningeal irritation, assessed by head elevation. Other tests evaluate reflexes or neurological signs unrelated to meningitis.
Question 2 of 5
A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Petechiae indicate thrombocytopenia, common in leukemia, increasing bleeding risk. Bleeding precautions (e.g., avoiding invasive procedures, using soft brushes) are essential to prevent hemorrhage, unlike the other options, which are irrelevant to this finding.
Question 3 of 5
A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale: Gentle flossing prevents plaque buildup without irritating mucositis-related sore gums. Hydrogen peroxide can worsen irritation, dentures may cause discomfort, and short brushing doesn't ensure oral hygiene.
Question 4 of 5
A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open their eyes, displays decerebrate posturing, and makes incomprehensible sounds. The nurse should assign the client which of the following Glasgow Coma Scale scores?
Correct Answer: D
Rationale: Glasgow Coma Scale: No eye opening (1), decerebrate posturing (abnormal extension, 2), incomprehensible sounds (2) = 1+2+2 = 5, reflecting severe neurological impairment.
Question 5 of 5
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
Correct Answer: D
Rationale: Antiviral therapy for genital herpes (e.g., acyclovir) is typically taken for a defined period, like 3 weeks for initial outbreaks, indicating understanding. Natural condoms don't prevent transmission, antibiotics are ineffective, and lesions resolve faster.