ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a complete spinal cord injury. Based on the nurse's understanding about the degree of this type of injury, what can the nurse expect will be the client's level of function?
Correct Answer: A
Rationale: Reason: This is the correct choice because a complete spinal cord injury is a condition where there is no motor or sensory function below the level of injury. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. The client will also have impaired thermoregulation, breathing, and blood pressure. The client will need 24-hour a day care to assist with mobility, hygiene, elimination, nutrition, and prevention of complications. Reason: This is incorrect because a client who is able to assist with transfer and perform self-care has a partial spinal cord injury, not a complete one. A partial spinal cord injury is a condition where there is some motor or sensory function below the level of injury. The degree of impairment depends on the extent and location of the damage. Reason: This is incorrect because a client who is able to roll over independently has a lower spinal cord injury, not a complete one. A lower spinal cord injury is a condition where there is damage to the lumbar or sacral segments of the spinal cord. The client will have paralysis of the lower limbs (paraplegia) and some loss of bladder, bowel, and sexual function. The client will still have some control over the upper limbs and trunk. Reason: This is incorrect because a client who is able to drive an electric wheelchair has an upper spinal cord injury, not a complete one. An upper spinal cord injury is a condition where there is damage to the cervical or thoracic segments of the spinal cord. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. However, the client may still have some movement or sensation in the shoulders, arms, or hands.
Question 2 of 5
A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?
Correct Answer: A
Rationale: First degree burns affect only the epidermis, causing redness and pain without blisters, as described. Second degree burns cause blisters, third degree burns destroy all skin layers, and the burn can be classified based on the symptoms.
Question 3 of 5
A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?
Correct Answer: D
Rationale: The NG tube decompresses the stomach and removes secretions, alleviating distension and preventing complications in acute peritonitis.
Question 4 of 5
A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?
Correct Answer: B
Rationale: Legal blindness is defined as a best-corrected visual acuity of 20/200 or worse in the better eye. Full vision loss in one eye, inability to see from 200 feet without lenses, or 20/60 impairment do not meet this criterion.
Question 5 of 5
A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?
Correct Answer: D
Rationale: Standing slightly in front and to one side of the client prevents collisions or falls by guiding them safely. Increasing voice volume, lowering bed rails prematurely, or using gestures are inappropriate for visually impaired clients.