ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L (nl. 135-145 mEq/L). Which of the following prescriptions should the nurse anticipate?
Correct Answer: C
Rationale: Restricting fluid intake is a key management strategy for SIADH to address the fluid overload and help correct the low sodium levels. This action directly targets the root cause of the hyponatremia by reducing fluid intake.
Question 2 of 5
A nurse is caring for a client who is experiencing pooling of blood in the periphery. Which of the following occurs in a client with distributive shock?
Correct Answer: B
Rationale: Decreased venous return occurs in distributive shock due to the pooling of blood in the periphery, leading to reduced preload and decreased cardiac output.
Question 3 of 5
A nurse is caring for a client who has a T4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?
Correct Answer: B
Rationale: Bladder distension is a common trigger for autonomic dysreflexia, a condition that occurs in individuals with spinal cord injuries at or above the T6 level, due to the excessive autonomic response to noxious stimuli such as a full bladder.
Question 4 of 5
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Clean gloves are appropriate for contact with the client or the wound, as MRSA is transmitted through direct contact. This prevents contamination while assessing the client.
Extract:
Nurses Notes
2100
Client arrives to ED with family who report client had been recovering well after a motor vehicle crash 2 weeks ago in which the client sustained an open head injury. Family members report that the client has become increasingly irritable over the last 2 days and has reported a headache since this morning. Family members report that as of this evening the client developed a fever and began throwing up.
2130:
Healthcare provider notified of assessment findings. Prescriptions received.
2200:
Lumbar puncture performed by healthcare provider using sterile technique. Tolerated well by client. Cerebral spinal fluid specimen labeled
Physical Examination
2115:
Awake, but drowsy. Oriented to person, place, and time. Client currently has a headache, reports pain as 8 on a scale of 0 to 10. Pupils are equal, round, and reactive to light. Client withdraws during pupil assessment verbalizing that the light is too bright and hurts their eyes. Unable to perform full range of motion of the neck due to nuchal rigidity. Kernig sign positive. Client is irritable and easily agitated during physical assessment.
Vital Signs
2105:
Temperature 38.9° C (102° F)
Heart rate 100/min
Respiratory rate 20/min
Blood pressure 129/79 mm Hg
SpO2 97% on room air
Healthcare Provider's Prescriptions
2145:
Computed tomography (CT) scan
Prepare for lumbar puncture
Cerebrospinal fluid analysis
Diagnostic Results
2330:
Cerebrospinal fluid (CSF) analysis
White blood cell (WBC) count 300 cells/microliter (nl. 0-10 cells/microliter)
Neutrophils 50% (nl. 0-6%)
Protein 85 mg/dL (nl. 15-45 mg/dL)
Glucose 40 mg/dL (nl. 50-75 mg/dL)
Color: Turbid (nl. clear and colorless)
Culture and sensitivity: Pending
Pressure 25 cm H2O (nl. less than 20 cm H20)
Question 5 of 5
The nurse should determine the assessment findings are consistent with which of the following disease processes? For each assessment finding, click to specify if the finding is consistent with bacterial meningitis or encephalitis. Each finding may support more than 1 disease process.
| Options | Bacterial Meningitis | Encephalitis |
|---|---|---|
| WBC count in CSF | ||
| Muscle weakness | ||
| Altered level of consciousness | ||
| Kernig sign result | ||
| Body temperature at 2105 |
Correct Answer: A,C,D,E
Rationale: A high WBC count in CSF is associated with bacterial meningitis. Muscle weakness and altered consciousness are prominent in encephalitis. Kernig sign supports bacterial meningitis. Elevated temperature is common in both.