ATI RN
ATI Nur 211 Med Surg Exam Unit 4 Questions
Extract:
Question 1 of 5
A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis?
Correct Answer: D
Rationale: Urine retention is not typically associated with appendicitis. Increased bowel motility is not specific to appendicitis, which may cause decreased motility. Gastric hyperacidity is related to gastritis or ulcers, not appendicitis. Rebound tenderness is a classic sign of appendicitis, indicating peritoneal irritation.
Question 2 of 5
The nurse is caring for a client with Clostridium Difficile. Which of the following infection control precautions should the nurse implement?
Correct Answer: A,B,C
Rationale: Gloves protect against C. diff spores. Restricting restroom use prevents spread. A private room isolates the infection. Alcohol-based sanitizers are ineffective against C. diff; soap and water are required. Masks are unnecessary as C. diff is not airborne.
Question 3 of 5
Which statement by the patient with chronic gastroesophageal reflux disease (GERD) indicates a need for further teaching?
Correct Answer: C
Rationale: Elevating the head of the bed is a recommended practice for individuals with GERD, as it helps prevent stomach acid from flowing back into the esophagus during sleep. This shows the patient is taking proactive steps to manage their condition. Using antacids can provide symptomatic relief from heartburn and discomfort associated with GERD. Taking them between meals and at bedtime can help neutralize stomach acid, which is a common practice for managing GERD symptoms. Eating large meals, especially rich or fatty foods, and snacking before bedtime can exacerbate GERD symptoms by increasing stomach pressure and acid production. Patients with GERD are typically advised to eat smaller meals and avoid eating close to bedtime to reduce reflux episodes. Chewing gum can actually be beneficial for some GERD patients as it stimulates saliva production, which can help neutralize stomach acid.
Question 4 of 5
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?
Correct Answer: D
Rationale:
Total bilirubin levels are primarily associated with liver function and hemolysis. While malnutrition can impact liver function, total bilirubin is not a direct indicator of nutritional status or malnutrition. Creatine kinase (CK) is an enzyme found in the heart, brain, and skeletal muscles. Its levels are typically associated with muscle damage or myocardial infarction. While malnutrition can impact muscle mass, CK is not specifically altered due to malnutrition alone. Troponin is a protein released when the heart muscle is damaged. It is primarily used as a biomarker for myocardial injury. Malnutrition does not directly affect troponin levels, so this is not a relevant finding in the context of malnutrition. Albumin is a protein produced by the liver and is a key indicator of nutritional status. Low albumin levels can indicate malnutrition, particularly protein deficiency. In cases of anorexia and malnutrition, albumin levels are often decreased due to inadequate protein intake and poor nutritional status.
Question 5 of 5
A 1-month old infant is admitted to the emergency room with severe diarrhea. Which of the following assessments suggests the infant is severely dehydrated?
Correct Answer: C
Rationale: A high specific gravity of urine typically indicates concentrated urine, which can occur in dehydration; however, moist mucous membranes suggest adequate hydration. This combination does not indicate severe dehydration. A low specific gravity of urine usually indicates dilute urine, which is not typical in dehydration; it suggests the kidneys are not concentrating urine due to good fluid intake or other factors. While pale skin can indicate poor perfusion, this option does not specifically indicate severe dehydration. A depressed fontanelle and a capillary refill time greater than 4 seconds are significant indicators of severe dehydration in infants. Depressed fontanelles suggest that the infant is not receiving enough fluids, and prolonged capillary refill time indicates poor perfusion and dehydration. Moist skin and mucous membranes indicate adequate hydration. Flushed skin may occur with certain conditions but does not suggest severe dehydration.