ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply)
Correct Answer: D,E
Rationale: Loosening restrictive clothing improves breathing and circulation, and placing a pillow under the head prevents injury. Placing the client supine risks aspiration, restraints can cause injury, and inserting a bite stick can damage teeth or obstruct the airway.
Question 2 of 5
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
Correct Answer: C
Rationale: Talking with the client during wound care provides emotional support by using therapeutic communication to distract, reassure, and address the client's feelings during a stressful procedure.
Question 3 of 5
A client diagnosed with cholecystitis reports right upper quadrant pain that radiates to the right shoulder. Which of the following interventions are the priority for the nurse to implement?
Correct Answer: D
Rationale: Assessing the pain level is the priority intervention for a client with cholecystitis. Pain is the most common symptom and can indicate the severity and complications of the condition. The nurse should use a numeric or descriptive scale to assess pain and monitor changes in location, intensity, and duration.
Question 4 of 5
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
Correct Answer: B
Rationale: Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis. Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease. Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy. Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.
Question 5 of 5
A client arrives to the clinic with reports of progressive weakness in his lower extremities. Which of the following findings in the client's history is consistent with the client developing Guillain-Barre syndrome?
Correct Answer: D
Rationale: Reason: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves. Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases. Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection. Reason: This is the correct answer because cytomegalovirus is one of the common infections that can trigger Guillain-Barre syndrome. It can cause inflammation and damage to the myelin sheath that covers the nerves.