ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.
Question 2 of 5
A nurse is assessing a client who has Parkinson disease. Which of the following manifestations should the nurse expect?
Correct Answer: D
Rationale: Bradykinesia, or slowness of movement, is a hallmark symptom of Parkinson's disease. It is characterized by a gradual reduction in the speed of voluntary movements and is one of the primary motor symptoms associated with the disease.
Question 3 of 5
The nurse is caring for a client in neurogenic shock following an overdose of anti-anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?
Correct Answer: D
Rationale: Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic stimulation resulting from the loss of sympathetic nervous system control.
Question 4 of 5
A nurse is planning care for a client who has leukemia and a platelet count of 60,000/mm³ (nl. 140,000-400,000/mm³). Which intervention should the nurse include in the plan of care?
Correct Answer: B
Rationale: Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
Extract:
Medical History
Client admitted with report of polyuria and polydipsia.
Notable muscle twitching of upper extremities.
Past medical history: Varicella as a child. No other health issues.
Current medications: Occasional ibuprofen for pain.
Family history: Father had history of nephrogenic diabetes insipidus.
Physical Examination
Alert and oriented to person, place, and time.
Client states that they have had difficulty concentrating lately and are irritable.
Client reports occasional dizziness.
Skin is warm, dry, and scaly.
Mucous membranes dry and pink.
Lungs clear to auscultation bilaterally.
Abdomen soft, nondistended with active bowel sounds x 4.
Denies nausea, vomiting, or diarrhea.
Peripheral pulses 1+
Twitching noted in upper extremities, client states they have had twitching "for some time."
Nurses' Notes
0845:
Needed assistance to the bathroom, reports dizziness.
Urine output 1,500 mL.
Assisted client to bed.
Vitals taken.
Vital Signs
0800:
Temperature 37.4° C (99.4° F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 108/78 mm Hg
SpO2 98% on room air
0900:
Temperature 37.4° C (99.4° F)
Heart rate 104/min
Respiratory rate 22/min
Blood pressure 96/70 mm Hg
Diagnostic Results
Basic metabolic profile
Sodium 157 mEq/L (nl. 136-145 mEq/L)
Potassium 3.49 mEq/L (nl. 3.5-5 mEq/L)
Chloride 102 mEq/L (nl. 98-106 mEq/L)
Magnesium 1.8 mEq/L (nl. 1.8-2.6 mEq/L)
Total calcium 9.7 mg/dL (nl. 8.8-10.4 mg/dL)
Complete blood count (CBC) with differential
Total white blood cell (WBC) count 6,500/mm3 (nl. 5,000-10,000/mm3)
Neutrophils 60% (55% to 70%)
Lymphocytes 30% (20% to 40%)
Monocytes 5% (2% to 8%)
Eosinophils 2.5% (1% to 4%)
Basophils 0.7% (0.5% to 1%)
Hemoglobin 21 g/dL (Male: 14 to 18 g/dL; Female: 12 to 16 g/dL)
Hematocrit 55% (Male: 42% to 52%; Female: 37% to 47%)
RBCs 5.7 x 106µL (Male: 4.7 to 6.1 x 106µL; Female: 4.2 to 5.4 x 106µL
Question 5 of 5
Complete the following sentence by using the lists of options. The nurse should first address the client's..... followed by the client's.....
Correct Answer: A,B
Rationale: Elevated sodium level (157 mEq/L) indicates hypernatremia, requiring urgent correction. Blood pressure should be addressed next to ensure stability.