ATI Gastrointestinal /Neuro Med Surg Detailed Answer Key Graded A

1. A A. Dextrose 5% in water Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water could cause rapid shifts in serum levels of some substances. B. 0.9% sodium chloride Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride could cause rapid shifts in serum levels of some substances. C. Dextrose 10% in water Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% or 20% in water until the next container of TPN solution arrives. D. Lactated Ringer’s solution Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution could cause rapid shifts in serum levels of some substances. 2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. “You should decrease your caloric intake when abdominal pain is present.” Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase their caloric intake in order to maintain weight. B. “You should increase your daily intake of protein.” Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein. C. “You should increase fat intake when experiencing loose stools.” Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent stimulation of the pancreas and steatorrhea. D. “You should limit alcohol intake to 2-3 drinks per week.” Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation of the pancreas. 3. (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness Rationale: Violent headache is correct. The client who manifests ICP should display a violent headache Neck pain and stiffness is incorrect. The client who manifests ICP should not display neck pain and stiffness Slurred speech is correct. The client who manifests ICP may display slurred speech. Projectile vomiting is correct. The client who manifests ICP may display sudden onset of projectile vomiting. Rapid loss of consciousness is correct. The client who manifests ICP may display a sudden rapid loss of consciousness. 4. A A. Severe headache Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation. B. Bradycardia Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not bradycardia. C. Increased muscle tone Rationale: The nurse should find as a sign of meningococcal meningitis decreased not increased muscle tone. D. Oriented to time, person, place Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not orientation to time, person, and place. 5. A A. bradycardia. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. B. ipsilateral pupil dilation. Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure displaces the brain against the optic nerve, but pupil dilation is not an early sign of increased ICP. C. widening pulse pressure. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. D. lethargy. Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. An early sign of increasing ICP is lethargy. 6. A. NPO until dysphagia subsides Rationale: Making the client NPO provides no nutritional support and will not likely be prescribed. B. Supplements via nasogastric tube Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed. C. Initiation of total parenteral nutrition Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the ingestion, digestion, and absorption of essential nutrients. This nutritional therapy will not likely be prescribed. D. Soft residue diet Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty swallowing solids; therefore, this nutritional therapy will not likely be prescribed. 7. A. "Incorporate nonverbal cues in the conversation." Rationale: Nonverbal cues enhance the client’s ability to comprehend and use language. B. "Ask multiple choice questions as part of the conversation." Rationale: Simple questions requiring yes/no responses are better understood by the client. C. "Use a higher-pitched tone of voice when speaking." Rationale: Tone of voice is understood by clients with aphasia, unless they have a hearing impairment. D. "Use simple child-like statements when speaking." Rationale: It is important to respect the client and use age-appropriate communication. 8. A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of the following outcomes should the nurse expect from this client’s medication therapy? A. Increased sodium excretion Rationale: The primary action of spironolactone is to increase sodium excretion in the urines. B. Decreased urinary output Rationale: Spironolactone is a diuretic, thus it should increase urine output. C. Increased potassium excretion Rationale: Spironolactone is potassium-sparing. D. Decreased chloride excretion Rationale: Spironolactone promotes the excretion of chloride in the urine. 9. A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration Rationale: Dehydration is not considered a complication of the hypothermia blanket therapy. B. Seizures Rationale: Seizures are not considered a complication of the hypothermia blanket therapy. C. Burns Rationale: Burns are associated with the improper use of heating pads, not a hypothermia blanket. D. Shivering Rationale: The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption. 10. 10. A. Pupil response Rationale: The nurse should include pupil response as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. B. Deep tendon reflexes Rationale: The nurse should include deep tendon reflexes as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. C. Muscle strength Rationale: The nurse should include muscle strength as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. D. Level of consciousness Rationale: The nurse should examine the client’s level of consciousness as the most reliable indicator of cerebral status.