ATI RN
ATI Nur 211 Med Surg Exam Unit 4 Questions
Extract:
Question 1 of 5
A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?
Correct Answer: B
Rationale: Distended neck veins are typically associated with conditions that lead to increased central venous pressure, such as heart failure or fluid overload, not pyloric stenosis. Projectile vomiting is a classic symptom of pyloric stenosis due to the obstruction caused by the thickened pylorus, which prevents food from passing into the duodenum. A ridged abdomen can indicate underlying issues, such as peritonitis, but is not typical for pyloric stenosis. Red currant jelly stools are associated with intussusception, not pyloric stenosis.
Question 2 of 5
The nurse is caring for an elderly client admitted with anemia and malnutrition. Which of the following health care prescriptions would the nurse anticipate being included in the plan of care?
Correct Answer: A,B,D,E
Rationale: Oral feeding supplements provide nutrients for malnutrition. Daily weights monitor nutritional progress. A low protein diet is inappropriate as protein is needed for recovery. Pre-albumin levels assess nutritional status. Calorie counts ensure adequate intake.
Question 3 of 5
Which of the following increase the risk of developing Clostridium Difficile.
Correct Answer: B,C
Rationale: Living independently does not increase C. diff risk. A weakened immune system increases susceptibility. Antibiotics disrupt gut flora, promoting C. diff. Diarrhea and fever are symptoms, not risk factors.
Question 4 of 5
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?
Correct Answer: C
Rationale: Constipation can be uncomfortable and may require management, but it is not typically a direct complication of peptic ulcer disease. While it is important to address, it does not pose an immediate threat to the client’s health. Epigastric discomfort is a common symptom of peptic ulcer disease and can indicate that the ulcer is active or that the patient is experiencing gastric distress. However, it does not indicate a severe or life-threatening condition and should be managed but is not a priority finding. Hematemesis, or vomiting blood, is a serious symptom that indicates possible bleeding from the ulcer. This is a potentially life-threatening condition that requires immediate medical intervention, as it can lead to significant blood loss and complications such as shock. Dyspepsia refers to general digestive discomfort, which may include symptoms like bloating, nausea, and heartburn. While it is a common symptom in peptic ulcer disease, it does not indicate an urgent medical condition.
Question 5 of 5
What assessment findings support the diagnosis of peritonitis?
Correct Answer: D
Rationale: Abdominal cramping can occur with various gastrointestinal conditions, including peritonitis. However, it is not specific to peritonitis and may also be present in conditions like gastroenteritis or bowel obstruction. Profuse diarrhea is typically associated with gastrointestinal infections or inflammatory bowel diseases rather than peritonitis. In fact, peritonitis often leads to reduced bowel activity, potentially resulting in constipation rather than diarrhea. Hyperactive bowel sounds can occur in early stages of peritonitis but are not a classic finding. In many cases of peritonitis, bowel sounds may be diminished or absent due to the body’s response to inflammation. A hard, rigid abdomen indicates muscle guarding, which is the body’s response to inflammation and irritation of the peritoneum. This rigidity is often referred to as 'board-like' and is a key indicator of peritonitis.