ATI Nur 175 Med Surg Exam | Nurselytic

Correct Answer: A

Rationale: The sudden onset of a headache and numbness on one side of the body are potential signs of a stroke or other serious medical conditions. The most appropriate response is to assist the visitor to the emergency department for immediate evaluation and treatment. Time is critical in such scenarios, and prompt medical attention can significantly impact the outcome. While taking the visitor's blood pressure might provide some information, it is not sufficient to assess the severity of the symptoms. This action alone could delay necessary urgent care. Encouraging the visitor to lie down and see if the symptoms improve is not appropriate because it does not address the potential seriousness of the symptoms. Delaying medical evaluation could worsen the visitor's condition. Advising the visitor to call their primary care provider is not appropriate in this urgent situation. Immediate evaluation in the emergency department is necessary to rule out serious conditions like a stroke.

Correct Answer: B,D

Rationale: TCAs commonly cause weight changes and sexual dysfunction.

Correct Answer: A,B,C,E

Rationale:
Choice A reason: Confirming that the rehabilitation center has a room available at the time of transfer is essential to ensure the client has a designated space upon arrival. This helps prevent any delays or complications during the transfer process.
Choice B reason: Ensuring the client has possession of his valuables is important for safeguarding the client's personal belongings during the transfer. This task helps prevent any loss or misplacement of valuable items.
Choice C reason: Completing a transfer form for the receiving facility is a critical task that involves documenting the client's medical information, treatment plan, and other relevant details. This form ensures that the receiving facility has all the necessary information to continue the client's care seamlessly.
Choice D reason: While assessing how the client tolerates the transfer is important, it is typically done after the transfer has occurred, rather than being a responsibility of the nurse at the sending facility. This task is more relevant to the receiving facility's staff.
Choice E reason: Sending a copy of the client's chart with diagnostic and laboratory results ensures that the receiving facility has access to the client's medical history, test results, and other pertinent information. This facilitates continuity of care and informed decision-making.

Correct Answer: A

Rationale: Family history of depression indicates a genetic predisposition.

Correct Answer: D

Rationale: Obtaining a routine urine sample from a newly-admitted client is an important task for the nurse to delegate to assistive personnel (AP). While this is essential for assessing the client's baseline health status and planning further care, it is not as urgent as taking an arterial blood gas specimen to the laboratory, which is time-sensitive. Passing fresh water to clients on the unit is an essential routine task to ensure clients stay hydrated. However, this task does not have the same level of urgency compared to taking an arterial blood gas specimen to the laboratory. This can be done after more critical tasks are completed. Transporting a client to the radiology department for an x-ray is a necessary step in diagnostic imaging, but it does not carry the same level of urgency as taking an arterial blood gas specimen to the laboratory. Arterial blood gas results are critical for evaluating and managing a client's respiratory and metabolic status. Taking an arterial blood gas (ABG) specimen to the laboratory is a top priority because the results are time-sensitive and crucial for the immediate assessment and management of a client's respiratory and metabolic function. Delaying this task could impact the timely diagnosis and treatment of potentially serious conditions, making it the most urgent task to delegate first.