ATI Medical Surgical Content Mastery Exam

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

B. Infection

A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? Select all that apply A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures

A. Increased intracranial pressure B. Hydrocephalus E. Seizures

The nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side lying position B. Document the duration of the seizure C. Reorient the client to the environment D. Provide client hygiene

A. Keep the client in a side lying position

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer? A. Ketorolac B. Ketamine C. Meperidine D. Methadone

A. Ketorolac

A nurse is developing a plan of care for a client who is scheduled for a cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? Select all that apply A. "I think I might be pregnant" B. "I take warfarin" C. "I take antihypertensive medication" D. "I am allergic to shrimp" E. "I ate a light breakfast this morning"

A. "I think I might be pregnant" B. "I take warfarin" D. "I am allergic to shrimp" E. "I ate a light breakfast this morning"

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? Select all that apply A. "It is given to reduce swelling of the brain" B. "You will need to monitor for low blood sugar" C. "You might notice weight gain" D. "Tumor growth will be delayed" E. "It can cause you to retain fluids"

A. "It is given to reduce swelling of the brain" C. "You might notice weight gain" D. "It can cause you to retain fluids"

A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? Select all that apply A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia

A. Areas of paresthesia B. Involuntary eye movements E. Ataxia

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following actions should the nurse take to promote client compliance? Select all that apply A. Ask the dietitian to assist with meal planning B. Contact the clients support system C. Assess for age related cognitive awareness D. Encourage the use of daily medication dispenser E. Provide educational materials for home use

A. Ask the dietitian to assist with meal planning B. Contact the clients support system D. Encourage the use of daily medication dispenser E. Provide educational materials for home use

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse review? Select all that apply A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet C. Limit looking at flashing light D. Perform aerobic exercise E. Limit episodes of hypoventilation F. Use of aerosol hairspray is recommended

A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet C. Limit looking at flashing light

A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? Select all that apply A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP 15 mm Hg E. Headache

A. Disoriented to time place B. Restlessness and irritability C. Unequal pupils E. Headache

A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurses response? (Select all that apply) A. Exposure to metal wasting products B. Long-term estrogen therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection

A. Exposure to metal wasting products D. Previous heady injury E. History of herpes infection

A nurse in the emergency department is assessing a client who is unresponsive. The clients partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the clients airway? A. Head tilt, chin lift B. Modified Jaw thrust C. Hyperextension of the head D. Flexion of the head

A. Head tilt, chin lift

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A. Increase intake of deep yellow and orange vegetables B. Administer eye drops twice daily C. Avoid bending at the waist D. Wear an eye patch at night

A. Increase intake of deep yellow and orange vegetables

A nurse is assessing the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? Select all that apply A. Place the client in supine position B. Flex the clients hip and knee C. Place hands behind the clients neck D. Bend the clients head toward chest E. Straighten the clients flexed leg at the knee

A. Place the client in supine position C. Place hands behind the clients neck D. Bend the clients head toward chest

A nurse is assessing a client who has a seizure disorder. The client tells the nurse "I am about to have a seizure." Which of the following actions should the nurse implement? Select all that apply A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the clients clothing E. Protect the clients head with padding F. Restrain the client

A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the clients clothing E. Protect the clients head with padding

A nurse is making a home visit to a client who has AD. The clients partner states that the client is often disoriented to time and place is unsteady and has a history of wandering. Which of the following safety measures should the nurse review with the partner? Select all that apply A. Remove floor rugs B. Have door locks that can be easily opened C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

A. Remove floor rugs C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that apply) A. Remove wet clothing B. Maintain normal room temperature C. Apply warm blankets D. Use a rapid rewarming water of 40 to 42 E. Infuse warmed IV fluids

A. Remove wet clothing C. Apply warm blankets D. Use a rapid rewarming water of 40 to 42 E. Infuse warmed IV fluids

A nurse is reinforcing with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include? A. Rise slowly when standing B. Expect urine to become dark colored C. Avoid food containing tyramine D. Report any skin discoloration

A. Rise slowly when standing

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? Select all that apply A. Implement seizure precautions B. Perform neurologic checks four times a day C. Administer morphine for the report of neck and generalized pain D. Turn off room lights and television E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently

A. implement seizure precautions D. Turn off room lights and television E. monitor for impaired extraocular movements

A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable? Select all that apply A. Smoking on social occasions B. BMI of 28 C. Alopecia D. Trisomy 21 E. History of reflux

A. smoking on social occasions B. BMI of 28 E. History of reflux

A nurse is assessing a client who reports severe headache and stiff neck. The nurse's assessment reveals positive kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights

B Implement droplet precautions

A nurse is caring for a client who was just informed of a new diagnosis of breast cancer. The nurse evaluates the clients response. Which of the following statements by the client reflects a lack of understanding of an illness perspective? A. "I have no family history of breast cancer" B. "I need a second opinion. There is no lump" C. "I am glad we live in the city near several large hospitals" D. "I will schedule surgery next week, over the holidays"

B. "I need a second opinion. There is no lump"

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure" B. "Try to stay awake most of the night prior to the procedure" C. "The procedure will take approximately 15 minutes" D. "You will need to lie flat for 4 hours after the procedure"

B. "Try to stay awake most of the night prior to this procedure"

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? Select all that apply A. Use the Glasgow Coma Scale when assessing the client B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake E. Instruct the client to perform deep breathing and coughing exercises

B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake

A nurse in a providers office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? Select all that apply A. Pain is bilateral across the posterior occipital area B. Client experiences altered sleep wake cycle C. Headache occurs approximately 1 to 8 times daily D. Client describes headache pain ad dull and throbbing E. Nasal congestion and drainage occur

B. Client experiences altered sleep wake cylce C. Headache occurs approximately 1 to 8 times daily E. Nasal congestion and drainage occur

A nurse on a Medical Surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has a pressure injury of the right heel whose blood glucose is 300mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal pulse

B. Client who reports right calf pain and shortness of breath Rational: SOB could be from a PE

A nurse is assessing the client for changes in the level of consciousness using the glascow coma scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6=15 D. E2 + V2 + M4 =8

B. E3 + V4 + M4 = 11

A nurse is caring for a male older client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with the disease? Select all that apply A. Sex B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply) A. Induce vomitting B. Instill activated charcoal C. Perform a gastric lavage with aspiration D. Administer syrup of ipecac D. Infuse IV fluids

B. Instill activated charcoal C. Perform a gastric lavage with aspiration D. administer IV fluids

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids

B. Loss of cognitive function

A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor and has a respiratory rate of 12. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethasone 30 mg IV bolus BID B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain C. Ondansetron 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin 100 mg IV bolus TID

B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open angle glaucoma C. Macular degeneration D. Angle closure glaucoma

B. Open angle glaucoma

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? Select all that apply A. Decreased vision B. Pill rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression

B. Pill rolling tremor of the fingers C. Shuffling gait D. Drooling F. Lack of facial expression

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? A. Keep the call light near the client B. Place the client in a room close to the nurses station C. Encourage the client to ask for assistance D. Remind the client to walk with someone for support

B. Place the client in a room close to the nurses station

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? Select all that apply A. Monitor for bradycarida B. Provide an emesis basin at the bedside C. Administer antipyretic mediation D. Perform a skin assessment E. Keep the head of bed flat

B. Provide an emesis basin at the bedside C. Aminister antipyretic medication D. Perform a skin assessment

A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include? Select all that apply A. Provide three large balanced meals daily B. Record diet and fluid intake daily C. Document weight every other week D. Offer cold fluids such as milkshakes E. Offer nutritional supplements between meals

B. Record diet and fluid intake D. Offer cold fluids such as milkshakes E. Offer nutritional supplements between meals

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? A. Baked salmon B. Salted cashews C. Frozen strawberries D. Fresh asparagus

B. Salted cashews

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? A. "This medication will relieve my symptoms by causing my blood vessels to dilate" B. "I should take this medication daily to prevent the headaches from occurring" C. "I should expect facial flushing when I take this medication" D. "This medication will lower my sensitivity to food triggers"

C. "I should expect facial flushing when I take this medication"

A nurse is caring for a client who is receiving morphine via patient controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? A. "I'll wait to use the device until it is absolutely necessary" B. "I'll be careful about pushing the button so I dont get an overdose" C. "I should tell the nurse if the pain doesnt stop after I use this device" D. "I will ask my son to push the dose button when I am sleeping"

C. "I should tell the nurse if the pain doesnt stop after I use this device"

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if this same type of tumor can occur in other areas of the body. Which of the following responses should the nurse make? A. "It can spread to breasts and kidneys" B. "It can develop in your gastrointestinal tract" C. "It is limited to brain tissue" D. "It is probably started in another area of your body and spread to your brain"

C. "It is limited to brain tissue"

A nurse is providing teaching to the partner of a client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? A. "This medication should increase my husband's appetite" B. "This medication should help my husbands sleep better" C. "This medication should help by husband's daily function" D. "This medication should increase my husbands energy level"

C. "This medication should help by husands daily function"

A nurse is completing discharge teaching to the client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching A. "It is safe to use microwaves that are 1200 watts or less" B. "You should avoid the use of CT scans with contrast" C. "You should place a magnet over the implantable device when you feel an aura occurring" D. "It is recommended that you use ultrasound diathermy for pain management"

C. "You should place a magnet over the implantable device when you feel an aura occurring"

A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform Defibrillation B. Prepare for transcutaneous pacing C. Administer epinephrine D. Elevate the clients lower extremities

C. Administer epinephrine

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? Select all that apply A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

C. Blurred vision D. White pupils

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? A. Urinary Incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C. Bradypnea D. Orthostatic Hypotension E. Nausea

A nurse at a clinic is talking with a client who has cancer and takes extended release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? A. Phantom limb pain B. Mixed pain C. Breakthrough pain D. Neuropathic pain

C. Breakthrough pain

A nurse is caring for a client who displays manifestations of stage III Parkinson's disease. Which of the following actions should the nurse include? A. Recommend a community support group B. Integrate daily exercise routine C. Provide a walker for ambulation D. Perform ADL's for the client

C. Provide a walker for ambulation

A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking an antacid when on this medication B. Watch for receding gums when taking the medication C. Take medication at the same time everyday D. Provide a urine sample to determine therapeutic levels of the medication

C. Take the medication at the same time everyday

A nurse is reviewing the use of meningoccal vaccine (MCV 4) for prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection B. The vaccine is administered in a series of four doses C. The vaccine is recommended for adolescents before starting college D. The vaccine is initially given at 2 months of age

C. The vaccine is recommended for adolescents before starting college

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine headaches? A. "Do the headaches occur multiple times each day?" B. "Is your headache accompanied by profuse facial sweating?" C. "Does your headache occur on one side of your head?" D. "Do you have the same manifestations each time the headache occurs?"

D. "Do you have the same manifestations each time the headache occurs?"

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors" B. "This medication will help you with your bladder function" C. "This medication can cause your skin to bruise easily" D. "This medication can cause you to experience dizziness"

D. "This medication can cause you to experience dizziness"

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days" B. "You need to tilt your head back when washing your hair" C. "You can get water in your eyes in 1 day" D. "You need to limit your housekeeping activities"

D. "You need to limit your housekeeping activities"

A nurse in a health care clinic is evaluating the level of wellness for clients using the illness wellness continuum tool. The nurse should identify which of the following clients as being at the center of the continuum? A. A college student who has influenza B. An older adult who has a new diagnosis of type 2 diabetes mellitus C. A new mother who has a urinary tract infection D. A young male client who has a long history of well controlled rheumatoid arthritis

D. A young male client who has a long history of well controlled rheumatoid arthritis Rational: the center of the continuum is the clients normal state of health

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of the headache B. Increase physical activity when a headache is present C. Drink beverages that contain artificial sweeteners to prevent headaches D. Apply a cool cloth to the face during a headache

D. Apply a cool cloth to the face during a headache

A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? A. Teach the client to walk more quickly when ambulating B. Complete passive range of motion exercises daily C. Place the client on a low protein, low calorie diet D. Give the client extra time to perform activities

D. Give the client extra time to perform activities

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take assess for this finding? A. Stroke the lateral aspect of the sole of the foot B. Ask the client to blink both eyes C. Observe for facial drooping D. Have the client stand erect eyes closed

D. Have the client stand erect eyes closed

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? A. Most clients exaggerate their pain level B. Pain must have an identifiable source to justify the use of opioids C. Objective data are essential in assessing pain D. Pain is whatever the client says it is

D. Pain is whatever the client says it is

A nurse working in a long term care facility is planning care for a client who has moderate Alzheimers (mild or moderate stage). Which of the following interventions should be included in the plan of care? A. Use a gait belt for ambulation B. Thicken all liquids C. Provide protective undergarments D. Reorient the client to self and current events

D. Reorient the client to self and current events