ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: A throbbing headache is a common symptom of meningitis due to increased intracranial pressure and meningeal irritation. Inability to read suggests a stroke or brain tumor, bruising around the eyes suggests a skull fracture, and a heart rate of 50 suggests bradycardia, none of which are typical for meningitis.
Question 2 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 3 of 5
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: A throbbing headache is a common symptom of meningitis due to increased intracranial pressure and meningeal irritation. Inability to read suggests a stroke or brain tumor, bruising around the eyes suggests a skull fracture, and a heart rate of 50 suggests bradycardia, none of which are typical for meningitis.
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: Reason: Requesting the charge nurse put the client on the surgery schedule is not the best first action, as it does not address the urgency of the situation. The client may have a perforated appendix, which is a life-threatening complication that requires immediate intervention. Reason: Documenting the WBC count from the morning labs is not the best first action, as it does not address the client's current condition. The WBC count may be elevated due to inflammation or infection, but it does not indicate the severity of the problem. Reason: This is the correct choice. Notifying the healthcare provider is the best first action, as it alerts them to the possibility of a perforated appendix and allows them to order appropriate tests and treatments. Reason: Providing an antiemetic is not the best first action, as it does not address the underlying cause of the vomiting. The client may have peritonitis, which is inflammation of the abdominal cavity due to leakage of intestinal contents. An antiemetic may mask this symptom and delay diagnosis and treatment.
Question 5 of 5
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
Correct Answer: A
Rationale: The client needs total nursing care is the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which is a tool that measures the level of consciousness based on eye opening, verbal response, and motor response. A score of 6 indicates severe brain injury and coma, meaning that the client is unresponsive and dependent on others for all activities of daily living. Indicates stable neurologic status is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A stable neurologic status means that there are no changes in the level of consciousness, vital signs, or neurological signs. The client has a decline in level of consciousness but is able to protect his airway is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A decline in level of consciousness means that the client is less alert and responsive than normal, but still able to respond to stimuli and maintain airway patency. The client is alert and oriented is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. Alert and oriented means that the client is fully awake and aware of person, place, time, and situation.