MED SURG EXAM 3 ATI PRACTICE
EXAM QUESTIONS AND ANSWERS
A nurse is providing discharge instructions for a client following cataract surgery with
insertion of an intraocular lens. Which of the following instruction should the nurse
include? - Answer-Restrict lifting objects greater than 10 pounds
Rationale: the nurse instruct the client to restrict lifting objects greater than 10 pounds to
reduce the rest for increased interocular pressure
A nurse is caring for a client who has expressive aphasia following a cerebrovascular
accident (CVA). Which of the following parameters should the nurse use first in order to
assess the client's pain level? - Answer-A self-report pain rating scale
Rationale: expressive aphasia results from damage to an area of the frontal lobe and is
a motor speech problem. The client who has expressive aphasia is able to understand
what is sad, but is unable to communicate verbally. However, this does not necessarily
mean that a client is unable to reliably report pain. evidence based practice indicates
the nurse should first attempt to obtain the client self report of pain. When assessing a
client for pain, the nurse should utilize the hierarchy of pain measures which begins with
self report. It is always better to use a subjective method, such as a client report,
instead of an objective method, such as something that is observable by the nurse,
which is much less reliable.
A nurse is assessing a client who has a concussion from a sports injury. Which of the
following manifestations should the nurse expect? - Answer-Sensitivity to light
Rationale: the nurse should expect a client who has a mild traumatic brain injury, such
as a concussion, to have sensitivity to light and noise
A nurse is caring for a client who has aphasia following a stroke. A family member asks
the nurse how she should communicate with the client. Which of the following
responses by the nurse is appropriate? - Answer-Incorporate nonverbal cues in the
conversation
Rationale: nonverbal cues, enhance the client's ability to comprehend and use language
A nurse is caring for a client who has Parkinson's disease and is taking
diphenhydramine 25 mg PO TID. Which of the following therapeutic outcome should the
nurse expect to see? - Answer-Decreased tremors
Rationale: Clients who have Parkinson's disease often experience trembling, muscle
rigidity, difficulty walking and problems with balance and coordination. Antihistamines,
like diphenhydramine, have a mild anticholinergic effect and may be helpful in
controlling tremors in the early stage of the disease.
,A nurse is caring for a client who is unconscious following a cerebral hemorrhage.
Which of the following nursing interventions is of highest priority? - Answer-Suction
saliva from the clients mouth
Rationale: the unconscious client is unable to independently maintain a clear airway and
is at risk for ineffective airway clearance according to the safety and risk reduction
priority setting framework, maintaining the clients airway, breathing, and circulation is
the highest priority
Patient admitted with a possible diagnosis of infective endocarditis and prescribed
gentamicin. Client is exhibiting signs of headache, dizziness, nausea and tinnitus.
Client's diagnostic lab wailers also indicated an increase in BUN, creatinine, gentamicin
peak level, AST/ALT. - Answer-The nurse should identify that the priority hypothesis is
that the greatest risk for the client is developing hearing loss due to antibiotics.
Ototoxicity may occur in clients who are receiving aminoglycosides, such as gentamicin.
An increase in BUN, creatinine, gentamicin peak level, ALT/AST all place the client at
risk for ototoxicity and hearing loss. Hearing loss is generally in the high frequency
range and is associated with peak aminoglycoside levels that continue to remain
elevated.
A nurse is caring for a client following cataract surgery. Which of the following
comments from the client should the nurse report to the clients provider? - Answer-"I
need something for the pain in my eye. I can't stand it"
Rationale: following cataract surgery, the client should expect only mild pain and should
immediately report any pain, decrease in vision, or increase in discharge from the eye.
Severe eye pain after surgery might indicate increased intraocular pressure or
hemorrhage.
A nurse is assessing a client who has a spinal cord injury. Which of the following action
should the nurse take to monitor C4 function? - Answer-Apply downward pressure while
the client shrugs their shoulders upward
Rationale: this assessment monitors the motor function of C4 to C5
A nurse is planning care for a client who had a traumatic brain injury and is emerging
restlessly from a coma. which of the following intervention should the nurse include in
the plan? - Answer-Reduce stimuli
Rationale: the nurse should reduce stimuli by decreasing the number of visitors,
speaking calmly, and creating a quiet environment
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3
vertebra. When planning care, the nurse anticipate which of the following types of
disability? - Answer-Paraplegia
, Rationale: Paraplegia or paralysis of both legs, is seen after a SCI below T1
A nurse is caring for a client four hours following evacuation of a subdural hematoma.
Which of the following assessment is the nurses priority? - Answer-Respiratory status
Rationale: When using the airway, breathing,
circulation approach to client care, the nurse should place the priority on assessing the
client's respirations, noting the rate and pattern and evaluating arterial blood gases.
Following intercranial surgery, even slight hypoxia can worsen cerebral ischemia.
A nurse is caring for an older adult client who has dementia and handles anxiety by
confabulating. The nurse should recognize confabulation when the client .. - Answer-
Makes up stories when he is unable to remember actual events
Rationale: Confabulating is filling in gaps in memory by fabrication. A client who has
dementia may do this unconsciously to cover for and decrease anxiety about memory
gaps.
A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed
selegiline, an MAOI. Which of the following foods should the nurse eliminate? - Answer-
Cheddar cheese
Rationale: the nurse should eliminate aged cheeses from the diet of a client who is
prescribed selegiline. Cheddar cheese contains tyramine, which can cause a
hypertensive crisis.
A nurse is assessing a client who has meningitis. Which of the following findings should
the nurse expect? - Answer-Severe headache
Rationale: the nurse should expect a client who has meningitis to manifest a severe
headache due to meningeal inflammation.
A nurse is caring for a client who has had a stroke involving the right hemisphere.
Which of the following alterations in function should the nurse expect? - Answer-Inability
to recognize his family members
Rationale: the right hemisphere is involved with visual and spatial awareness. A client
who is unable to recognize faces would have involvement with the right hemisphere.
A nurse is caring for a 24 year old client who reports a recent fall, hitting their head and
right shoulder after slipping on a wet floor yesterday. Denies LOC. Complains of pain in
right shoulder. Has taken both acetaminophen and ibuprofen for pain with minimal relief
obtained. Stayed up entire night playing video games yesterday to distract self from
pain. Reports intermittent nausea and vomiting.
EXAM QUESTIONS AND ANSWERS
A nurse is providing discharge instructions for a client following cataract surgery with
insertion of an intraocular lens. Which of the following instruction should the nurse
include? - Answer-Restrict lifting objects greater than 10 pounds
Rationale: the nurse instruct the client to restrict lifting objects greater than 10 pounds to
reduce the rest for increased interocular pressure
A nurse is caring for a client who has expressive aphasia following a cerebrovascular
accident (CVA). Which of the following parameters should the nurse use first in order to
assess the client's pain level? - Answer-A self-report pain rating scale
Rationale: expressive aphasia results from damage to an area of the frontal lobe and is
a motor speech problem. The client who has expressive aphasia is able to understand
what is sad, but is unable to communicate verbally. However, this does not necessarily
mean that a client is unable to reliably report pain. evidence based practice indicates
the nurse should first attempt to obtain the client self report of pain. When assessing a
client for pain, the nurse should utilize the hierarchy of pain measures which begins with
self report. It is always better to use a subjective method, such as a client report,
instead of an objective method, such as something that is observable by the nurse,
which is much less reliable.
A nurse is assessing a client who has a concussion from a sports injury. Which of the
following manifestations should the nurse expect? - Answer-Sensitivity to light
Rationale: the nurse should expect a client who has a mild traumatic brain injury, such
as a concussion, to have sensitivity to light and noise
A nurse is caring for a client who has aphasia following a stroke. A family member asks
the nurse how she should communicate with the client. Which of the following
responses by the nurse is appropriate? - Answer-Incorporate nonverbal cues in the
conversation
Rationale: nonverbal cues, enhance the client's ability to comprehend and use language
A nurse is caring for a client who has Parkinson's disease and is taking
diphenhydramine 25 mg PO TID. Which of the following therapeutic outcome should the
nurse expect to see? - Answer-Decreased tremors
Rationale: Clients who have Parkinson's disease often experience trembling, muscle
rigidity, difficulty walking and problems with balance and coordination. Antihistamines,
like diphenhydramine, have a mild anticholinergic effect and may be helpful in
controlling tremors in the early stage of the disease.
,A nurse is caring for a client who is unconscious following a cerebral hemorrhage.
Which of the following nursing interventions is of highest priority? - Answer-Suction
saliva from the clients mouth
Rationale: the unconscious client is unable to independently maintain a clear airway and
is at risk for ineffective airway clearance according to the safety and risk reduction
priority setting framework, maintaining the clients airway, breathing, and circulation is
the highest priority
Patient admitted with a possible diagnosis of infective endocarditis and prescribed
gentamicin. Client is exhibiting signs of headache, dizziness, nausea and tinnitus.
Client's diagnostic lab wailers also indicated an increase in BUN, creatinine, gentamicin
peak level, AST/ALT. - Answer-The nurse should identify that the priority hypothesis is
that the greatest risk for the client is developing hearing loss due to antibiotics.
Ototoxicity may occur in clients who are receiving aminoglycosides, such as gentamicin.
An increase in BUN, creatinine, gentamicin peak level, ALT/AST all place the client at
risk for ototoxicity and hearing loss. Hearing loss is generally in the high frequency
range and is associated with peak aminoglycoside levels that continue to remain
elevated.
A nurse is caring for a client following cataract surgery. Which of the following
comments from the client should the nurse report to the clients provider? - Answer-"I
need something for the pain in my eye. I can't stand it"
Rationale: following cataract surgery, the client should expect only mild pain and should
immediately report any pain, decrease in vision, or increase in discharge from the eye.
Severe eye pain after surgery might indicate increased intraocular pressure or
hemorrhage.
A nurse is assessing a client who has a spinal cord injury. Which of the following action
should the nurse take to monitor C4 function? - Answer-Apply downward pressure while
the client shrugs their shoulders upward
Rationale: this assessment monitors the motor function of C4 to C5
A nurse is planning care for a client who had a traumatic brain injury and is emerging
restlessly from a coma. which of the following intervention should the nurse include in
the plan? - Answer-Reduce stimuli
Rationale: the nurse should reduce stimuli by decreasing the number of visitors,
speaking calmly, and creating a quiet environment
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3
vertebra. When planning care, the nurse anticipate which of the following types of
disability? - Answer-Paraplegia
, Rationale: Paraplegia or paralysis of both legs, is seen after a SCI below T1
A nurse is caring for a client four hours following evacuation of a subdural hematoma.
Which of the following assessment is the nurses priority? - Answer-Respiratory status
Rationale: When using the airway, breathing,
circulation approach to client care, the nurse should place the priority on assessing the
client's respirations, noting the rate and pattern and evaluating arterial blood gases.
Following intercranial surgery, even slight hypoxia can worsen cerebral ischemia.
A nurse is caring for an older adult client who has dementia and handles anxiety by
confabulating. The nurse should recognize confabulation when the client .. - Answer-
Makes up stories when he is unable to remember actual events
Rationale: Confabulating is filling in gaps in memory by fabrication. A client who has
dementia may do this unconsciously to cover for and decrease anxiety about memory
gaps.
A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed
selegiline, an MAOI. Which of the following foods should the nurse eliminate? - Answer-
Cheddar cheese
Rationale: the nurse should eliminate aged cheeses from the diet of a client who is
prescribed selegiline. Cheddar cheese contains tyramine, which can cause a
hypertensive crisis.
A nurse is assessing a client who has meningitis. Which of the following findings should
the nurse expect? - Answer-Severe headache
Rationale: the nurse should expect a client who has meningitis to manifest a severe
headache due to meningeal inflammation.
A nurse is caring for a client who has had a stroke involving the right hemisphere.
Which of the following alterations in function should the nurse expect? - Answer-Inability
to recognize his family members
Rationale: the right hemisphere is involved with visual and spatial awareness. A client
who is unable to recognize faces would have involvement with the right hemisphere.
A nurse is caring for a 24 year old client who reports a recent fall, hitting their head and
right shoulder after slipping on a wet floor yesterday. Denies LOC. Complains of pain in
right shoulder. Has taken both acetaminophen and ibuprofen for pain with minimal relief
obtained. Stayed up entire night playing video games yesterday to distract self from
pain. Reports intermittent nausea and vomiting.
