ATI Med Surg (p. 21-98)
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, B, C, E
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, D
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? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea
C, D, E
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 level of pain. 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
A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. "I should restrict rapid movements and avoid bending from the waist for several weeks." B. "I should wait until the day after surgery to wash my hair." C."I will remove the dressing behind my ear in 7 days." D."My hearing should be back to normal right after my surgery."
A
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
A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching? A. Rise slowly when standing. B. Expect urine to become dark‐colored. C. Avoid foods containing tyramine. D. Report any skin discoloration.
A
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 include in this review? (Select all that apply.) A. Avoid overwhelming fatigue. B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. D. Perform aerobic exercise. E. Limit episodes of hypoventilation. F. Use of aerosol hairspray is recommended.
A, B, C
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension
A, B, D
A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (Select all that apply.) A. Reduce exposure to bright lighting. B. Move head slowly when changing positions. C. Do not eat fruit high in potassium. D. Plan evenly spaced daily fluid intake. E. Avoid fluids containing caffeine.
A, B, D, E
A nurse is caring for an older adult 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 client's support system. C. Assess for age‐related cognitive awareness. D. Encourage the use of a daily medication dispenser. E. Provide educational materials for home use.
A, B, D, E
A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. 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, B, D, E
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, B, E
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, B, E
A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (Select all that apply.) A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine
A, B, E
A nurse is assessing for 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 client in supine position. B. Flex client's hip and knee. C. Place hands behind the client's neck. D. Bend client's head toward chest. E. Straighten the client's flexed leg at the knee.
A, C, D
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. Apply a heat lamp E. Infuse warmed IV fluids
A, C, D, E
A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady on his feet, 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, C, D, E
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, C, E
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 may notice weight gain." D. "Tumor growth will be delayed." E. "It can cause you to retain fluids."
A, C, E
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 nurse's response? (Select all that apply.) A. Exposure to metal waste products B. Long‐term estrogen therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection
A, D, E
A nurse is planning care for a client who has meningitis and is at risk for increased ICP. Which of the following actions should the nurse plan to take? (Select all that apply) A. Implement seizure precautions B. Perform neurological 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, D, E
A nurse is assessing a client for changes in the LOC using the Glasgow 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
A nurse is caring for a client who was just told she has breast cancer. The nurse evaluates the client's 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
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 the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension
B
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
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria
B
A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. 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
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
A nurse is caring for an older adult 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
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
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 an ulceration of the right heel whose blood glucose is 300 mg/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
A nurse in a provider's 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 at approximately the same time of the day. D. Client describes headache pain as dull and throbbing E. Nasal congestion and drainage occur.
B, C E
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, C, D
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 bradycardia. B. Provide an emesis basin at the bedside. C. Administer antipyretic medication. D. Perform a skin assessment. E. Keep the head of the bed flat.
B, C, D
A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply.) A. Gender B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus
B, C, D, E
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, C, D, F
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 vomiting. B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. D. Administer syrup of ipecac. E. Infuse IV fluids.
B, C, E
A nursing is caring for a client who has a closed‐head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.
B, D
A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which actions should the nurse include in the plan of care? (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. Place the client in Fowler's position to eat. E. Offer nutritional supplements between meals.
B, E
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 headache from occurring." C."I should expect facial flushing when I take this medication." D."This medication will lower my sensitivity to food triggers."
C
A nurse is assessing a client who is reporting pain despite analgesia. Which of the following actions should the nurse take to assess the intensity of the client's pain? A. Ask the client what precipitates his pain. B. Question the client about the location of his pain. C. Offer the client a pain scale to measure his pain. D. Use open‐ended questions to identify the sensation of his pain.
C
A nurse is caring for a client who displays signs of stage III Parkinson's disease. Which of the following actions should the nurse include in the plan of care? A. Recommend a community support group. B. Integrate a daily exercise routine. C. Provide a walker for ambulation. D. Perform ADLs for the client.
C
A nurse is caring for a client who is receiving morphine via a 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's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C."I should tell the nurse if the pain doesn't stop after I use this device." D."I will ask my son to push the dose button when I am sleeping."
C
A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? 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 probably started in another area of your body and spread to your brain."
C
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response
C
A nurse is completing discharge teaching to a 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 1,200 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
A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication.
C
A nurse is providing teaching to the partner of an older adult 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 husband sleep better." C."This medication should help my husband's daily function." D."This medication should increase my husband's energy level."
C
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 IV epinephrine. D. Elevate the client's lower extremities.
C
A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the 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
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 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
A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss
D
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 findings of migraine headaches? A. "Do the headaches occur at the same time each day?" B. "Is your headache accompanied by profuse facial sweating?" C."Does your headache occur on one side of your head?" D."Is there a pattern of headaches among family members?"
D
A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. Pearly, gray tympanic membrane (TM) B. Malleus visible behind the TM C. Presence of soft cerumen in the external canal D. Fluid bubble seen behind the TM
D
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
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
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 to assess for this sign? A. Stroke the lateral aspect of the sole of the foot. B. Ask the client to blink his eyes. C. Observe for facial drooping. D. Have the client stand erect with eyes closed.
D
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 may cause your skin to bruise easily." D. "This medication may cause your skin to appear yellow in color."
D
A nurse working in a long‐term care facility is planning care for a client in stage V of Alzheimer's disease. 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. Assist with ADLs.
D
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
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is 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 client's clothing. E. Protect the client's head with padding. F. Restrain the client.
A, B, C, D, E
A nurse is caring for a client who was recently admitted to the emergency department following a head‐on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.
A
normal IOP range
10-21
A nurse is assessing a client who reports severe headache and a 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
A nurse in the emergency department is assessing a client who is unresponsive. The client's 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 client's airway? A. Head‐tilt, chin‐lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head
A
A nurse is assessing the pain level of a client who came to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following components of a pain assessment? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors
A
A 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
