ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?
Correct Answer: A
Rationale: The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important for individuals with SLE, maintaining an overly cold environment can also trigger symptoms, as cold temperatures can lead to vasoconstriction and Raynaud's phenomenon, which is common in SLE patients.
Question 2 of 5
A diabetes nurse educator is discussing 'sick day rules' with a client newly diagnosed with diabetes mellitus type 1. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: It is crucial for clients with diabetes to continue taking insulin during illness, even if they are unable to eat. Insulin needs may increase due to stress or infection, and not taking insulin could lead to hyperglycemia or diabetic ketoacidosis. Checking blood sugar every 2 hours is correct, but insulin should not be omitted.
Question 3 of 5
A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?
Correct Answer: D
Rationale: Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.
Question 4 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.
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.