ATI Adult Med Surg assessment

A nurse is assessing a client who has permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively? a. "I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league." b. "I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running." c. "I'm so upset that this happened to me. What did I do to deserve this, and why am I not getting better?" d. "I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family."

I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league." (rationale) This statement shows that the client has accepted the disability and the need to adapt abilities. This also shows that the client is looking towards the future and setting realistic goals.

A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe? a. 4 g sodium diet b. Potassium-restricted diet c. High-phosphorous diet d. High-protein diet

Potassium-restricted diet (rationale) Clients who have chronic kidney disease should be encouraged to consume a diet that is low in potassium and protein. The nurse should consult the provider for an appropriate diet prescription.

A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the clients on their side, which of the following medications should the nurse administer? a. Diazepam IV b. Lorazepam PO c. Diltiazem IV d. Clonazepam PO

a. Diazepam IV (rationale) Diazepam is the medication of choice for a client who has status epilepticus. The nurse should administer the medication to provide emergency treatment because the onset of action is within 10 min.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration? a. Pitting edema of bilateral lower extremities b. Hypoactive bowel sounds in all four quadrants c. Weight is the same as the day before d. Bilateral posterior lung sounds are diminished

a. Pitting edema of bilateral lower extremities (rationale) the nurse should identify that pitting edema can indicate fluid overload, which is a potential complication of the administration of TPN.

A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately? a. distended, board like abdomen b. WBC count 15,000 mm c. rebound tenderness over McBurney's point d. temperature 37.3 c

a. distended, board like abdomen (rationale) The greatest risk to the client is injury from a ruptured appendix causing peritonitis. Therefore, the priority finding the nurse should report to the provider is the manifestation of a distended board-like abdomen. Peritonitis, which is an inflammation of the peritoneum and viscera, is a medical emergency.

A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign? a. After stroking the lateral area of the foot, the client's toes contract and draw together. b. After hip flexion, the client is unable to extend their leg completely without pain. c. The client's voluntary movement is not coordinated. d. The client reports pain and stiffness when flexing their neck.

b. After hip flexion, the client is unable to extend their leg completely without pain. (rationale) A client who is unable to extend their leg completely without pain after hip flexion is demonstrating a positive Kernig's sign, which indicates the presence of meningeal irritation.

A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection? a. Stomatitis b. Fatigue c. Wasting syndrome d. Lipodystrophy

b. Fatigue (rationale) A client who has an early HIV infection can either be asymptomatic or can experience fever, rash, and fatigue. Other early manifestations of HIV are similar to those of viral infections.

A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO 2 times daily. Which of the following instructions should the nurse include in the teaching? a. Monitor for increased blood pressure. b. Increase intake of high-potassium foods. c. Expect an increase in swelling in the hands and feet. d. Take the second dose at bedtime.

b. Increase intake of high-potassium foods. (rationale) The nurse should instruct the client that hypokalemia is an adverse effect of furosemide. The client should increase their intake of high-potassium foods.

A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client's plan? (select all that apply) a. Initiate insulin drip. b. Monitor blood glucose levels. c. Continue regular diet as tolerated. d. Maintain NPO status until pain-free. e. Manage acute pain.

b. Monitor blood glucose levels. d. Maintain NPO status until pain-free. e. Manage acute pain. (raionale) Monitor blood glucose levels is correct. The client is at risk for hyperglycemia. The nurse should monitor the client's blood glucose levels and provide insulin as needed. Maintain NPO status until pain-free is correct. The client should remain NPO until pain-free to decrease the secretion of pancreatic enzymes, which should result in decreasing inflammation of the pancreas. Continuing a regular diet will only increase the secretion of pancreatic enzymes and cause further inflammation and pain. Manage acute pain is correct. Classic manifestations of an acute attack include severe, constant, and knife-like pain. The client will require pain medication to treat the pain, decrease gastrointestinal tract activity, and reduce pancreatic stimulation during the acute exacerbation phase.

A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO2 29mm Hg (35 to 45 mm Hg), and HCO3 25 mEq/L (21 to 28 mEq/L). The nurse should recognize that the client has which of the following acid-base imbalances? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

b. Respiratory alkalosis (rationale) Hyperventilation causes respiratory alkalosis because the client is exhaling excessive amounts of carbon dioxide. Carbon dioxide loss decreases the hydrogen ion concentration, causing the pH to increase and resulting in respiratory alkalosis.

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider? a. The dressing was changed 7 days ago. b. The circumference of the client's upper arm has increased by 10%. c. The catheter has not been used in 8 hr. d. he catheter has been flushed with 10 mL of sterile saline after medication use.

b. The circumference of the client's upper arm has increased by 10%. (rationale) Circumference of the upper arm above the insertion site of the PICC should be measured at the time of insertion and then again during assessments. An increase in the circumference could indicate deep-vein thrombosis, which could be life threatening. The nurse should contact the provider immediately about this finding.

A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in teaching? a. immunosuppressant medications need to be taken for up to a year b. shortness of breath might be an indication of transplant rejection c. the surgical site will heal in 3 to 4 weeks after surgery d. begin 45 minutes of moderate aerobic exercise per day following discharge

b. shortness of breath might be an indication of transplant rejection (rationale) Shortness of breath is an indication of transplant rejection. Other manifestations include fatigue, edema, bradycardia, and hypotension. Clients who have had an organ transplant should be educated on the manifestations of rejection and when to contact their provider.

A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet? a. 1 packet of reconstituted dry onion soup b. 3 oz of lean cured ham c. 3 oz of chicken breast d. 1/2 cup of canned baked beans

c. 3 oz of chicken breast (rationale) A low-sodium diet is recommended for a client who has hypertension. Therefore, the nurse should determine that 3 oz of chicken breast is the best food choice to recommend because it contains 30 to 90 mg of sodium.

A nurse is planning care for a client who has acute post-streptococcal glomerulonephritis. Which of the following interventions should the nurse include in the client's plan? a. Encourage a high-protein diet for the client. b. Increase the client's fluid intake. c. Administer diuretics to the client. d. Weigh the client twice a week.

c. Administer diuretics to the client. (rationale) The management of glomerulonephritis focuses on relieving manifestations. Sodium and fluid restriction and diuretic therapy help reduce the edema that characterizes glomerulonephritis.

A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). Which of the following statements by the client indicates an understanding of the teaching? a. "I should not wash my hair prior to the procedure." b. "I will receive a sedative 1 hour before the procedure." c. "I should avoid eating prior to the procedure." d. "I will be exposed to flashes of light during the procedure."

d. "I will be exposed to flashes of light during the procedure." (rationale) he nurse should tell the client that flashes of light or pictures are often used by the technician during the procedure to assess the client's response to stimuli and to determine the potential for seizures.

A nurse is caring for a client who has burn injures covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make? a. "It is okay to not want to touch the burned areas of your body." b. "Cosmetic surgery should be performed within the next year to be effective." c. "Reconstructive surgery can completely restore your previous appearance." d. "It could be helpful for you to attend a support group for people who have burn injuries."

d. "It could be helpful for you to attend a support group for people who have burn injuries." (rationale) The nurse should encourage the client to attend a support group for clients who have burn injuries. Support groups, informational sessions, and counseling are interventions that can help the client with the acceptance of their appearance. The nurse should assist the client with finding a support group, if desired.

A nurse is teaching a client about fcal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? a. "Your provider will use stool from your digital rectal examination to perform the test." b. "Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel." c. "You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old." d. "You should avoid taking corticosteroids prior to testing."

d. "You should avoid taking corticosteroids prior to testing." (rationale) The nurse should instruct the client to avoid taking corticosteroids, anti-inflammatory medications, and vitamin C prior to testing to prevent false positive results

A nurse is planning care for a client who has Ménière's disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan? a. Maintain strict bed rest. b. Restrict fluid intake to the morning hours. c. Administer aspirin. d. Provide a low-sodium diet.

d. Provide a low-sodium diet. (rationale) Ménière's disease is an inner ear disorder that affects the client's balance. Limiting sodium in the diet reduces fluid retention, which decreases the manifestations of the disease.

A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching? a. Explain procedures in full detail to a client before initiating care. b. ​Limit a client's activities to minimize emotional outbursts. c. Speak clearly and loudly to a client who is unable to form words or sentences. d. Provide supervision to prevent a client from becoming injured or lost.

d. Provide supervision to prevent a client from becoming injured or lost. (rationale) A client who has Alzheimer's disease can wander and become lost. The AP should initiate interventions to keep the client safe, such as redirection, frequent monitoring, and reorientation.