Exam Retake 2 ATI RN Medical
Surgical Med Surg A with
rationales
A home health nurse is assigned to a client who was recently
discharged from a rehabilitation center after experiencing a right-
hemispheric stroke. Which of the following neurologic deficits should
the nurse expect to find when assessing the client? (Select all that
apply.) A. Expressive aphasia B. Visual spatial deficits C. Left
hemianopsia D. Right hemiplegia E. One-sided neglect - B, C, E
Expressive aphasia is incorrect. Expressive aphasia, or an inability to
express what one wants to convey, occurs secondary to a left-
hemispheric stroke. Visual spatial deficits is correct. Visual spatial
deficits and loss of depth perception occur secondary to a right-
hemispheric stroke. Left hemianopsia is correct. Left hemianopsia,
or blindness in the left half of the visual field, occurs secondary to a
right-hemispheric stroke. Right hemiplegia is incorrect. Right
hemiplegia occurs secondary to a left-hemispheric stroke. One-
sided neglect is correct. One-sided neglect, or an unawareness of
the affected side, occurs secondary to a right-hemispheric stroke. A
nurse and an assistive personnel (AP) are caring for a client who
has bacterial meningitis. The nurse should give the AP which of the
following instructions? A. Wear a mask B. Wear a gown C. Keep the
client's room well-lit D. Maintain the head of the bed at a 45
elevation - A. Wear a mask Bacterial meningitis requires droplet
precautions; therefore, the AP and the nurse should wear a mask
when coming within 0.9 m (3 ft) of the client until 24 hr after the
client has begun receiving antibiotic therapy. A nurse has received
,change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first? A. A client who is 1 day
postoperative following abdominal surgery and reports pain of 4 on
a scale from 0 to 10 B. A client who had a myocardial infarction
(MI) 4 days ago and is asking for a PRN sublingual nitroglycerin
tablet C. A client who has atopic dermatitis manifestations with
scaling and excoriation of the skin and reports severe itching D. A
client who has pneumonia manifestations with bilateral crackles
and diminished breath sounds - B. A client who had a myocardial
infarction (MI) 4 days ago and is asking for a PRN sublingual
nitroglycerin tablet When using the stable vs. unstable approach to
client care, the nurse should assess this client first. A client who
had a myocardial infarction 4 days ago and is asking for a PRN
sublingual nitroglycerin tablet could be unstable. This client might
be experiencing angina or could be having another MI. A nurse in a
community clinic is caring for a client who reports an increase in
the frequency of migraine headaches. To help reduce the risk for
migraine headaches, which of the following foods should the nurse
recommend the client to avoid? A. Shellfish B. Aged cheese C.
Peppermint candy D. Enriched pasta - B. Aged cheese Foods that
contain tyramine, such as aged cheese and sausage, can trigger
migraine headaches. A nurse in a provider's office is assessing a
client who has hypertension and takes propranolol. Which of the
following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication? A. Report of a
night cough B. Report of tinnitus C. Report of excessive tearing D.
Report of increased salivation - A. Report of a night cough The
nurse should recognize that a night cough is an early indication of
heart failure and report this adverse reaction to the provider. A
nurse in a provider's office is assessing a client who has migraine
headaches and is taking feverfew to prevent headaches. The nurse
should identify that which of the following client medications
, interacts with feverfew? A. Metoprolol B. Bupropion C. Naproxen D.
Atorvastatin - C. Naproxen Both naproxen and feverfew impair
platelet aggregation and place the client at risk for bleeding. A
nurse in a provider's office is caring for a client who requests
sildenafil to treat erectile dysfunction. Which of the following
statements should the nurse make? A. "You might need to take a
stool softener while taking this medication" B. "You will not be able
to use sildenafil if you have diabetes" C. "You will need to limit your
caffeine intake if you start taking sildenafil" D. "You will not be able
to use sildenafil if you are taking nitroglycerin" - D. "You will not
be able to use sildenafil if you are taking nitroglycerin" The client
should not use sildenafil when taking nitroglycerin because both
medications can cause vasodilation and lead to significant
hypotension. A nurse in an acute care facility is caring for a client
who is at risk for seizures. Which of the following precautions
should the nurse implement? A. Place a padded tongue blade at the
client's bedside B. Keep the side rails lowered on the client's bed C.
Maintain the client's bed at hip level or above D. Ensure the client
has a patent IV - D. Ensure the client has a patent IV The nurse
should ensure the client has IV access in the event that the client
requires medication to stop seizure activity. A nurse in an
emergency department is assessing a client who has a detached
retina. Which of the following should the nurse expect the client to
report? A. "It's like a curtain closed over my eye" B. "This sharp
pain in my eye started 2 hours ago" C. "I've been having more and
more difficulty seeing over the last few weeks" D. "I seem to have
more problems seeing different colors" - A. "It's like a curtain closed
over my eye" A retinal detachment is the separation of the retina
from the epithelium. It can occur because of trauma, cataract
surgery, retinopathy, or uveitis. Clients who have retinal
detachment typically report the sensation of a curtain being pulled
over part of the visual field. A nurse in an emergency department
Surgical Med Surg A with
rationales
A home health nurse is assigned to a client who was recently
discharged from a rehabilitation center after experiencing a right-
hemispheric stroke. Which of the following neurologic deficits should
the nurse expect to find when assessing the client? (Select all that
apply.) A. Expressive aphasia B. Visual spatial deficits C. Left
hemianopsia D. Right hemiplegia E. One-sided neglect - B, C, E
Expressive aphasia is incorrect. Expressive aphasia, or an inability to
express what one wants to convey, occurs secondary to a left-
hemispheric stroke. Visual spatial deficits is correct. Visual spatial
deficits and loss of depth perception occur secondary to a right-
hemispheric stroke. Left hemianopsia is correct. Left hemianopsia,
or blindness in the left half of the visual field, occurs secondary to a
right-hemispheric stroke. Right hemiplegia is incorrect. Right
hemiplegia occurs secondary to a left-hemispheric stroke. One-
sided neglect is correct. One-sided neglect, or an unawareness of
the affected side, occurs secondary to a right-hemispheric stroke. A
nurse and an assistive personnel (AP) are caring for a client who
has bacterial meningitis. The nurse should give the AP which of the
following instructions? A. Wear a mask B. Wear a gown C. Keep the
client's room well-lit D. Maintain the head of the bed at a 45
elevation - A. Wear a mask Bacterial meningitis requires droplet
precautions; therefore, the AP and the nurse should wear a mask
when coming within 0.9 m (3 ft) of the client until 24 hr after the
client has begun receiving antibiotic therapy. A nurse has received
,change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first? A. A client who is 1 day
postoperative following abdominal surgery and reports pain of 4 on
a scale from 0 to 10 B. A client who had a myocardial infarction
(MI) 4 days ago and is asking for a PRN sublingual nitroglycerin
tablet C. A client who has atopic dermatitis manifestations with
scaling and excoriation of the skin and reports severe itching D. A
client who has pneumonia manifestations with bilateral crackles
and diminished breath sounds - B. A client who had a myocardial
infarction (MI) 4 days ago and is asking for a PRN sublingual
nitroglycerin tablet When using the stable vs. unstable approach to
client care, the nurse should assess this client first. A client who
had a myocardial infarction 4 days ago and is asking for a PRN
sublingual nitroglycerin tablet could be unstable. This client might
be experiencing angina or could be having another MI. A nurse in a
community clinic is caring for a client who reports an increase in
the frequency of migraine headaches. To help reduce the risk for
migraine headaches, which of the following foods should the nurse
recommend the client to avoid? A. Shellfish B. Aged cheese C.
Peppermint candy D. Enriched pasta - B. Aged cheese Foods that
contain tyramine, such as aged cheese and sausage, can trigger
migraine headaches. A nurse in a provider's office is assessing a
client who has hypertension and takes propranolol. Which of the
following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication? A. Report of a
night cough B. Report of tinnitus C. Report of excessive tearing D.
Report of increased salivation - A. Report of a night cough The
nurse should recognize that a night cough is an early indication of
heart failure and report this adverse reaction to the provider. A
nurse in a provider's office is assessing a client who has migraine
headaches and is taking feverfew to prevent headaches. The nurse
should identify that which of the following client medications
, interacts with feverfew? A. Metoprolol B. Bupropion C. Naproxen D.
Atorvastatin - C. Naproxen Both naproxen and feverfew impair
platelet aggregation and place the client at risk for bleeding. A
nurse in a provider's office is caring for a client who requests
sildenafil to treat erectile dysfunction. Which of the following
statements should the nurse make? A. "You might need to take a
stool softener while taking this medication" B. "You will not be able
to use sildenafil if you have diabetes" C. "You will need to limit your
caffeine intake if you start taking sildenafil" D. "You will not be able
to use sildenafil if you are taking nitroglycerin" - D. "You will not
be able to use sildenafil if you are taking nitroglycerin" The client
should not use sildenafil when taking nitroglycerin because both
medications can cause vasodilation and lead to significant
hypotension. A nurse in an acute care facility is caring for a client
who is at risk for seizures. Which of the following precautions
should the nurse implement? A. Place a padded tongue blade at the
client's bedside B. Keep the side rails lowered on the client's bed C.
Maintain the client's bed at hip level or above D. Ensure the client
has a patent IV - D. Ensure the client has a patent IV The nurse
should ensure the client has IV access in the event that the client
requires medication to stop seizure activity. A nurse in an
emergency department is assessing a client who has a detached
retina. Which of the following should the nurse expect the client to
report? A. "It's like a curtain closed over my eye" B. "This sharp
pain in my eye started 2 hours ago" C. "I've been having more and
more difficulty seeing over the last few weeks" D. "I seem to have
more problems seeing different colors" - A. "It's like a curtain closed
over my eye" A retinal detachment is the separation of the retina
from the epithelium. It can occur because of trauma, cataract
surgery, retinopathy, or uveitis. Clients who have retinal
detachment typically report the sensation of a curtain being pulled
over part of the visual field. A nurse in an emergency department
