ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Play serene soothing music. Music therapy has been shown to be effective in reducing anxiety and agitation in individuals with dementia. Serene music can help create a calming environment, promoting relaxation and potentially improving the client's overall well-being. Encouraging visits from friends (
Choice
A) may overwhelm the client with dementia. Applying restraints to the upper extremities (
Choice
B) is not recommended as it can lead to physical and psychological harm. Keeping the over-the-bed light on (
Choice
D) may disrupt the client's sleep and exacerbate confusion.
Question 2 of 5
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve.
Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve.
Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
Question 3 of 5
A nurse is providing teaching to a client who is considering a total hip arthroplasty. The client asks the nurse, 'What happens if I need a blood transfusion during my surgery?' Which of the following statements should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: "You can donate your own blood a few weeks prior to this surgery." This is the correct answer because autologous blood donation involves donating your own blood before surgery to be transfused back to you if needed. This reduces the risk of transfusion reactions and ensures a compatible blood match. Option A is incorrect because family members are not typically required to donate blood for surgery. Option B is incorrect as total hip arthroplasty can involve significant blood loss. Option D is incorrect as even with screened donor blood, transfusion reactions can still occur.
Question 4 of 5
A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?
Correct Answer: D
Rationale: The correct answer is D: Ensure lights are dimmed in the client's room. Dimming the lights can help decrease stimulation and minimize discomfort for a client with bacterial meningitis, as they may be sensitive to light due to photophobia, which is a common symptom in meningitis. It can also help reduce the risk of exacerbating headaches and other symptoms.
Incorrect choices:
A: Initiating airborne precautions is not necessary for bacterial meningitis, as it is not transmitted through the air.
B: Ensuring the client's bed is positioned to greater than 45° is not directly related to the care of a client with bacterial meningitis.
C: Encouraging frequent ambulation may not be appropriate for a client with bacterial meningitis, as they may be too weak or ill to ambulate.
E, F, G: There are no additional choices provided, but they would likely be incorrect as they are not relevant to the care of a client with bacterial meningitis.
Question 5 of 5
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interact with this medication?
Correct Answer: B
Rationale: The correct answer is B: Kale. Kale is high in vitamin K, which can interfere with the anticoagulant effects of warfarin by increasing the clotting factors in the blood, leading to a decreased INR. It is important for patients on warfarin to maintain a consistent intake of vitamin K-rich foods to ensure their INR remains within the therapeutic range. Orange juice (
A), beef stew (
C), and yogurt (
D) do not significantly interact with warfarin. A summary of why they are incorrect: Orange juice does not have a direct interaction with warfarin. Beef stew does not contain significant amounts of vitamin K. Yogurt is not a high vitamin K food.