ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 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 2 of 5
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. The nurse should identify which of the following risks as the priority for assessment and intervention?
Correct Answer: A
Rationale: Airway obstruction is the priority due to potential edema, inflammation, or inhalation injury in burns of the head, neck, and chest, which can compromise oxygenation and lead to respiratory failure.
Question 3 of 5
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?
Correct Answer: A
Rationale: Sweating and pallor are early signs and symptoms of dumping syndrome, which is a condition where food moves too quickly from the stomach to the small intestine, causing rapid fluid shifts and hormonal changes. Sweating and pallor are caused by hypoglycemia, which occurs when the high concentration of food in the small intestine stimulates insulin secretion. Abdominal cramping and pain are late signs and symptoms of dumping syndrome, which occur about one to three hours after eating. Abdominal cramping and pain are caused by intestinal distension, spasms, and gas formation. Double vision and chest pain are not signs and symptoms of dumping syndrome, but may indicate other serious conditions, such as stroke or heart attack. Double vision and chest pain should be reported to the provider immediately. Bradycardia and indigestion are not signs and symptoms of dumping syndrome, but may be related to other gastrointestinal disorders, such as gastritis or peptic ulcer disease. Bradycardia and indigestion should be evaluated by the provider for further diagnosis and treatment.
Question 4 of 5
A client arrives with a pink eye that is itchy, swollen, and uncomfortable with a creamy discharge. Which of the following home care instructions will the nurse offer to the client?
Correct Answer: A
Rationale: Washing towels, sheets, and pillowcases prevents reinfection and transmission of conjunctivitis-causing bacteria or viruses (
Choice
A). Antifungal drops are ineffective, as conjunctivitis is typically bacterial or viral (
Choice
B). STI exams are irrelevant unless other STI symptoms are present (
Choice
C). Avoiding daylight is unnecessary; sunglasses can manage light sensitivity (
Choice
D).
Question 5 of 5
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
Correct Answer: D
Rationale: Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection. Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation. Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions. Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.