ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
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 1 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.
Extract:
Nurses' Notes
Family member brought client to the ED for pain in left arm that began last evening. Client has a history of sickle cell disease diagnosed at age 4 years. Client has prescription for oral morphine sulfate and took one dose last evening at 1800 and this morning at 0900. Client reports no relief from pain, reporting it as 9 on a scale of 0 to 10.
Physical Examination
Client appears in moderate distress, reporting throbbing and stabbing pain to the left arm and hand. Client has full range of motion to arm, wrist, and fingers but resists movement due to pain. Capillary refill is less than 2 seconds, skin warm and dry, no edema, no rashes, no lesions. Client has used oral morphine sulfate in the past to alleviate pain. Reports taking dose of morphine sulfate last night at 1800 with no relief. Took an additional dose of morphine sulfate at 0900 this morning and states, "I am in still in pain, the morphine didn't work." Heart rate regular with no murmur, lungs clear, abdomen soft and nontender.
Vital Signs
Blood pressure 114/68 mm Hg
Heart rate 98/min
Respiratory rate 18/min
Temperature 37.1° C (98.9° F)
SpO2 95% on room air
Question 2 of 5
For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Intravenous fluid administration | |||
| Ice packs to affected area 15 min on/15 min off | |||
| Ambulation in hallway with supervision | |||
| Hydromorphone intravenously (IV) for pain | |||
| Acetaminophen orally (PO) for pain | |||
| Oxygen 2 L/min via nasal cannula |
Correct Answer: A,D
Rationale: Intravenous fluid administration is anticipated to reduce viscosity of sickled cells. Hydromorphone IV is anticipated for severe pain unresponsive to oral morphine.
Extract:
Nurses Notes
Day 1:
Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.
Vital Signs
1200:
Temperature: 39.5°C (103.1°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
1300:
Temperature: 39.9°C (103.8°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
Diagnostic Results
1200:
Temperature: 39.5°C (103.1°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
1300:
Temperature: 39.9°C (103.8°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
Question 3 of 5
Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,D
Rationale: Encouraging fluid intake prevents dehydration. Wearing a mask prevents influenza spread. A private room reduces transmission risk.
Extract:
History and Physical
Day 1
Client works as a firearms instructor at a shooting range.
Hypertension
Heart failure
Osteoarthritis
Medication Administration Record
Day 1:
Gentamycin 500 mg by mouth (PO) daily
Bumetanide 2 mg PO daily
Naproxen 250 mg PO daily
Nurses' Notes
6 months later:
Client reports having trouble hearing in noisy places.
Client states they are hearing sounds as muffled.
Diagnostic Results
6 months later:
Audiometer test with hearing loss at 39 dB
Question 4 of 5
A nurse is reviewing a client's medical record. Select the 4 findings that place the client at risk for hearing impairment.
Correct Answer: B,C,D,E
Rationale: Employment at a shooting range, gentamycin, naproxen, and bumetanide are risk factors for hearing impairment due to noise exposure and ototoxicity.
Extract:
Nurses Notes
Day 3 of hospitalization:
0730
Fingerstick blood glucose, fasting 114 mg/dL (nl. 60 to 110 mg/dL)
NPH insulin 40 units subcutaneous administered into abdomen as prescribed
0830:
Client reports nausea with emesis; vomited morning meal
1130:
Client reports feeling shaky, hungry, skin cool and diaphoretic Fingerstick blood glucose 55 mg/dL (nl. 60 to 110 mg/dL)
Vital Signs
Day 3 of hospitalization:
0700:
Temperature 37.3 °C (99.1 °F)
Blood pressure 118/62 mm Hg
Heart rate 84/min
Respiratory rate 20/min
SpO2 97% on room air
1130:
Temperature 37.8 °C (100 °F)
Blood pressure 104/56 mm Hg
Heart rate 118/min
Respiratory rate 20/min
SpO2, 95% on room air
Diagnostic Results
Day 3 of hospitalization:
HbA1c: 8.01% (nl. 4.4-6,4% )
Question 5 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,D
Rationale: Hypoglycemia (glucose 55 mg/dL), shakiness, and elevated heart rate require immediate follow-up to manage low blood sugar and assess underlying causes.