ATI MEDSURG FINAL EXAM NEWEST 2024 ACTUAL
EXAM COMPLETE QUESTIONS AND 100%
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+ //BRAND NEW!!
A nurse is caring for a client who has a closed head injury and has an intraventricular
catheter placed. Which of the following findings indicates that the client is experiencing
increased intracranial pressure (ICP)? (Select all that apply)
-Flat jugular veins
-A Glasgow Coma Scale score of 15
-Sleepiness exhibited by the client
-Widening pulse pressure
-Decerebrate posturing - ANSWER Correct:
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client
from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
Signs of increased ICP: - ANSWER Irritability
Severe headache
Distended jugular veins
Decreased LOC (Glascow coma scale would not be 15).
Dilated or pinpoint pupils
Altered breathing (cheyne-stokes, hyperventilation, apnea)
Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP.
Widening pulse pressure. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Abnormal posturing. Both decerebrate and decorticate posturing indicate increased ICP.
Normal ICP: - ANSWER 10-15
Pulse pressure - ANSWER The difference between the systolic and diastolic pressures.
Cheyne-stokes - ANSWER Regular cycle where the rate and depth of breathing
increase, then decrease until apnea (usually about 20 seconds) occurs Duration of
apnea may vary and progressively lengthen; therefore, it is timed and reported.
, Associated with heart failure and damage to the respiratory center (drug induced, tumor,
trauma)
Hyper ventilation - ANSWER Increased rate and depth of breathing that results in
decreased PaCO2 level Inspiration and expiration nearly equal in duration Associated
with exertion, anxiety, and metabolic acidosis Called Kussmaul's respiration if
associated with diabetic ketoacidosis or renal origin
Biot's respiration - ANSWER Periods of normal breathing (3-4 breaths), followed by a
varying period of apnea (usually 10-60 seconds) Also called ataxic breathing;
associated with complete irregularity Associated with respiratory depression resulting
from drug overdose and brain injury, normally at the level of the medulla
Cheyne-stokes vs Biot's respirations - ANSWER There are subtle differences between
Cheyne-Stokes and Biot's respiration patterns. Between regularly cycled periods of
apnea, Cheyne-Stokes respirations demonstrate a regular pattern with the rate and
depth of breathing increasing and then decreasing. In Biot's respiration, irregularly
cycled periods of apnea are interspersed with cycles of normal rate and depth.
A nurse is preparing a client who has supraventricular tachycardia for elective
cardioversion. Which of the following prescribed medications should the nurse instruct
the client to withhold for 48 hr prior to cardioversion?
-Enoxaparin
-Metformin
-Diazepam
-Digoxin - ANSWER Correct:
Digoxin
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for ventricular
fibrillation after the synchronized countershock of cardioversion.
Other info:
-Anticoagulants (Enoxaparin) can be beneficial during cardioversion due to their ability
to prevent blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
-Metformin might be withheld for a client scheduled for cardiac catheterization or other
procedures involving contrast dye in order to prevent damage to the kidneys. However,
metformin should not be withheld prior to cardioversion.
-Sedatives (Diazepam) are generally administered to clients prior to cardioversion to
reduce anxiety and minimize the discomfort associated with the procedure. This
medication should not be withheld.
EXAM COMPLETE QUESTIONS AND 100%
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+ //BRAND NEW!!
A nurse is caring for a client who has a closed head injury and has an intraventricular
catheter placed. Which of the following findings indicates that the client is experiencing
increased intracranial pressure (ICP)? (Select all that apply)
-Flat jugular veins
-A Glasgow Coma Scale score of 15
-Sleepiness exhibited by the client
-Widening pulse pressure
-Decerebrate posturing - ANSWER Correct:
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client
from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
Signs of increased ICP: - ANSWER Irritability
Severe headache
Distended jugular veins
Decreased LOC (Glascow coma scale would not be 15).
Dilated or pinpoint pupils
Altered breathing (cheyne-stokes, hyperventilation, apnea)
Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP.
Widening pulse pressure. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Abnormal posturing. Both decerebrate and decorticate posturing indicate increased ICP.
Normal ICP: - ANSWER 10-15
Pulse pressure - ANSWER The difference between the systolic and diastolic pressures.
Cheyne-stokes - ANSWER Regular cycle where the rate and depth of breathing
increase, then decrease until apnea (usually about 20 seconds) occurs Duration of
apnea may vary and progressively lengthen; therefore, it is timed and reported.
, Associated with heart failure and damage to the respiratory center (drug induced, tumor,
trauma)
Hyper ventilation - ANSWER Increased rate and depth of breathing that results in
decreased PaCO2 level Inspiration and expiration nearly equal in duration Associated
with exertion, anxiety, and metabolic acidosis Called Kussmaul's respiration if
associated with diabetic ketoacidosis or renal origin
Biot's respiration - ANSWER Periods of normal breathing (3-4 breaths), followed by a
varying period of apnea (usually 10-60 seconds) Also called ataxic breathing;
associated with complete irregularity Associated with respiratory depression resulting
from drug overdose and brain injury, normally at the level of the medulla
Cheyne-stokes vs Biot's respirations - ANSWER There are subtle differences between
Cheyne-Stokes and Biot's respiration patterns. Between regularly cycled periods of
apnea, Cheyne-Stokes respirations demonstrate a regular pattern with the rate and
depth of breathing increasing and then decreasing. In Biot's respiration, irregularly
cycled periods of apnea are interspersed with cycles of normal rate and depth.
A nurse is preparing a client who has supraventricular tachycardia for elective
cardioversion. Which of the following prescribed medications should the nurse instruct
the client to withhold for 48 hr prior to cardioversion?
-Enoxaparin
-Metformin
-Diazepam
-Digoxin - ANSWER Correct:
Digoxin
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for ventricular
fibrillation after the synchronized countershock of cardioversion.
Other info:
-Anticoagulants (Enoxaparin) can be beneficial during cardioversion due to their ability
to prevent blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
-Metformin might be withheld for a client scheduled for cardiac catheterization or other
procedures involving contrast dye in order to prevent damage to the kidneys. However,
metformin should not be withheld prior to cardioversion.
-Sedatives (Diazepam) are generally administered to clients prior to cardioversion to
reduce anxiety and minimize the discomfort associated with the procedure. This
medication should not be withheld.
