ATI Medical Surgical Assessment F .Verified A+

ATI Medical Surgical Assessment F
.Verified A+
AVnurseVisVcaringVforVaVclientVwithVaVhistoryVofVcongestiveVheartVfailur
eVatVriskVforVdevelopmentVofVfluidVvolumeVexcess.VTheVnurseVshouldV
monitorVforVwhichVofVtheVfollowingVthatVisVaVmanifestationVofVleftVsided
VheartVfailure?

SwellingVofVtheVfingersVandVhands

JugularVneckVveinVdistension

3+VankleVedema

DyspneaVwithVaVcoughVthatVisVworseVatVnightV-
VDyspneaVwithVaVcoughVthatVisVworseVatVnight
DyspneaVwithVaVcoughVthatVisVworseVatVnightVisVanVindicationVofVleft-
sidedVheartVfailure.VLeft-
sidedVheartVfailureVcausesVbloodVtoVbackVupVinVtheVheartVandVlungsVwithVd
ecreasedVdistributionVofVbloodVthroughoutVtheVbody.

WhichVclientVproblemVshouldVreceiveVhighestVpriorityVwhenVaVclientVisVadmitte
dVwithVanVacuteVexacerbationVofVrheumatoidVarthritis?

DifficultyVwithVhygieneVandVgrooming
VImpairedVphysicalVmobility
Body-imageVdisturbance
AnxietyV-VImpairedVphysicalVmobility
WhenVsettingVprioritiesVforVnursingVcare,VphysiologicalVneedsVshouldVbeVadd
ressedVfirstVaccordingVtoVMaslow'sVHierarchyVofVNeeds.VReducingVtheVclient'
sVpainVwillVhelpVwithVotherVneeds,VsuchVasVhygieneVandVgrooming.

AVnurseVisVcaringVforVaVclientVwithVhypoparathyroidism.VBecauseVofVtheVpote
ntialVelectrolyteVdisturbanceVassociatedVwithVthisVdiagnosis,VtheVnurseVshouldV
observeVtheVclientVforVevidenceVofVwhichVofVtheVfollowing?

ElevatedVbloodVpressureVIn
voluntaryVmuscleVspasmsV
ColdVintolerance
WeightVlossV-VInvoluntaryVmuscleVspasms
AVdecreaseVinVparathormoneVsecretionVleadsVtoVhypocalcemiaV(decreasedVser
umVcalciumVlevels),VwhichVmayVcauseVtetany.VInvoluntaryVmuscleVspasmsVare
VaVcommonVsymptomVassociatedVwithVhypothyroidism.

AVclientVwithVglaucomaVisVadmittedVforVsurgeryVtheVfollowingVday.VTheVclient
VisVtoVcontinueVtreatingVtheVglaucomaVwithVpilocarpineV(Pilocar)V2%V1VdropV
4VtimesVaVday.VWhileVinstillingVthisVmedication,VanVappropriateVnursingVactio
nVisVwhichVofVtheVfollowing?

InstructVtheVclientVtoVblinkVseveralVtimesVafterVinstillationVofVtheVmedi
cation.VAskVtheVclientVtoVlookVstraightVahead.

,PlaceVtheVmedicationVinVtheVconjunctivalVsacVapplyingVpressureVtoVtheVpunc
taVforV1VtoV2Vmin.
DabVexcessVmedicationVfromVtheVeyeVusingVaVcottonVballV10VtoV15Vseconds
VafterVinstillation.V-
VPlaceVtheVmedicationVinVtheVconjunctivalVsacVapplyingVpressureVtoVtheVpunc
taVforV1VtoV2Vmin.
EyeVdropsVareVinstilledVintoVtheVconjunctivalVsacVandVpressureVappliedVtoV
theVpunctaVforV1VtoV2VminVtoVpreventVlossVofVmedicationVintoVtheVnasalVl
acrimalVductVandVintoVtheVsystemicVcirculation.

AVclientVhasVsprainedVanVankleVwhileVplayingVsoccer.VForVtheVfirstV24VhrVfoll
owingVtheVinjury,VtheVnurseVshouldVinstructVtheVclientVtoVdoVwhichVofVtheVfol
lowing?

PerformVgentleVrangeVofVmotionV(ROM)VexercisesVonVtheVankleVjointVtoVprev
entVcontractures.
KeepVmoistVheatVonVtheVankleVtoVpreventVmuscleVspasm.
KeepVtheVfootVinVaVdependentVpositionVtoVaideVcirculationVtoVtheVfoot.
KeepViceVonVtheVankleVtoVpreventVedema.V-
VKeepViceVonVtheVankleVtoVpreventVedema.VIceVorVcoldVwillVconstrictVbloodV
vesselsVtoVtheVinjuredVareaVdecreasingVswelling.VNerveVimpulseVtransmissionV
willValsoVbeVreduced,VresultingVinVanalgesiaVtoVtheVinjuredVareaVandVaVreduc
tionVofVmuscleVspasms.VIceVapplicationsVshouldVnotVexceedV20VtoV30VminVp
erVapplication.

AVnurseVisVassistingVwithVtheVdischargeVofVaVclientVnewlyVdiagnosedVwithVdi
abetes.VWhenVreviewingVinformationVaboutVproperVfootVcare,VwhichVofVtheVfoll
owingVwouldVbeVappropriateVtoVinclude?

SoakVfeetVeveryVnightVinVwarmVwat
er.VWearVcleanVcottonVsocksVdaily.
WalkVbarefootVatVhomeVwhenVpossible.
GetVfittedVforVshoesVinVtheVmorning.V-VWearVcleanVcottonVsocksVdaily.
CottonVsocksVshouldVbeVwornVbyVclientsVwhoVareVdiabetic.VTheyVareVsoftVan
dVwillVwickVexcessVmoistureVawayVfromVtheVfoot.

FollowingVaVtransientVischemicVattackV(TIA),VaVclientVisValert,VslightlyVconfus
ed,VandVhasVaVbloodVpressureVofV204/102VmmVHg.VTheVclientVisValsoVinco
ntinentVofVurine.
WhenVcontributingVtoVtheVclient'sVplanVofVcare,VwhichVnursingVactionVwouldVb
eVappropriate?

OfferVtheVclientVaVbedpanVeveryV2Vhr.
PlaceVanVadultVdiaperVonVtheVclientVandVcheckVeveryV2Vhr.
RequestVaVprescriptionVforVanVindwellingVurinaryVcatheterVfromVtheVclient's
Vprovider.VAmbulateVtheVclientVtoVtheVbathroomVeveryV4Vhr.V-
VOfferVtheVclientVaVbedpanVeveryV2Vhr.
TheVeffectsVofVaVTIAVareVusuallyVtemporary,VandVtheVnurseVshouldVtryVtoVhe
lpVtheVclientVregainVbladderVcontrol.VThisVoptionVhelpsVtheVclientVregainVblad
derVcontrol,VusesVanVappropriateVtimeVintervalV(2Vhr)VforVbladderVtraining,Van
dVkeepsVtheVclientVsafeVbyVmaintainingVbedVrest.

, AVnurseVisVreinforcingVteachingVtoVaVclientVrecentlyVdiagnosedVwithVsystemic
VlupusVerythematosusV(SLE).VWhichVstatementVmadeVbyVtheVclientVindicatesVt
oVtheVnurseVanVaccurateVunderstandingVofVtheVhomeVmanagementVofVSLE?

"IVwillVneedVtoVtakeVprednisoneVwhenVIVamVhavingVanVexacerbationVofVtheV
disease."V"I'mVthankfulVthisVconditionVonlyVaffectsVtheVskinVbecauseVIVwillVjus
tVneedVtoVstayVoutVofVtheVsun."
"AVwarmVshowerVforV10VtoV15VminutesVeveryVeveningVwillVreallyVhelpVtoVloo
senVupVmyVjoints."
"AVmildVfeverVisVcommonVwithVSLEVandVusuallyVdoesVnotVrequireVmedicalVi
ntervention."V-
V"IVwillVneedVtoVtakeVprednisoneVwhenVIVamVhavingVanVexacerbationVofVth
eVdisease."
SLEVisVanVautoimmuneVdisorderVcharacterizedVbyVflaresVorVexacerbationsVwi
thVperiodicVremissions.VItVaffectsVtheVskinVasVwellVasVjoints,Vorgans,VandVa
nyVstructureVinVtheVbodyVthatVcontainsVconnectiveVtissue.VPrednisoneV(Delta
sone)VisVtheVmedicationVmostVcommonlyVgivenVtoVdecreaseVtheVbody'sVinfla
mmatoryVresponseVandVsubsequentlyVdecreaseVpainVinVaffectedVjoints/organs/
tissuesVandVfatigue.VLong-
termVtherapyVwithVcorticosteroidsVposeVsignificantVsideVeffectsVsoVclientsVare
VusuallyVweanedVoffVtheseVmedicationsVwhenVtheVexacerbationVhasVsubside
d.

AVnurseVisVcaringVforVaVclientVwhoVhasVundergoneVaVhipVarthroplasty.VTheV
nurseVremindsVtheVclientVthatVtheVpurposeVofVanVabductionVpillowVfollowingVa
rthroplastyVisVtoVdoVwhichVofVtheVfollowing?

RaiseVtheVbedVlinensVoffVtheVclient'sVfeetVpreventingVplantarV
flexion.VKeepVtheVclient'sVheelsVoffVtheVbedVtoVpreventVpress
ureVulcers.
PositionVtheVclientVoffVofVtheVoperativeVsiteVwhileVinVbed.
PreventVdislocationVofVtheVhipVduringVpositionVchangesVorVmovement.V-
VPreventVdislocationVofVtheVhipVduringVpositionVchangesVorVmovement.
TotalVhipVarthroplastyVisVaVsurgicalVprocedureVtoVreconstructVaVdiseasedVhip
Vjoint.VTheVheadVofVtheVfemurVisVremoved,ValongVwithVtheVliningVofVtheVac
etabulumV(hipVsocket).VTheVheadVofVtheVfemurVisVreplacedVwithVaVmetalVba
llVandVstem,VandVtheVacetabulumVisVreplacedVwithVaVplasticVorVmetalVcup.V
FollowingVsurgery,VtheVclientVmustVbeVonV"hipVprecautions"VtoVpreventVdislo
cationVofVtheVnewVhipVjoint.VTheVabductionVpillowVisVaVwedge-
shapedVpillowVthatVisVplacedVbetweenVtheVlegs.VTheVpurposeVofVtheVabduct
ionVpillowVisVtoVpreventVadductionVbeyondVtheVmidlineVofVtheVbodyVfollowin
gVtotalVhipVreplacementVduringVpositionVchangesVorVclientVmovement.
TQLogicTMVTheVmostVimportantVstepVofVTQLogicVusedVinVansweringVthisVqu
estionVisVcomprehensionVandVreliesVonVbasicVnursingVknowledge.VInVexaminin
gVtheVcriticalVelementVofVtheVtestVquestion,VtheVissueVofVtheVquestionVisVthe
VpurposeVofVanVabductorVpillowVfollowingVhipVarthroplasty.VAnVabductionVpillo
wVorVsplintVisVusedVfollowingVtotalVhipVarthroplastyVtoVpreventVadductionVbey
ondVtheVmidlineVofVtheVbodyVandVpreventVpossibleVdislocation.

AVclientVwhoVisVadmittedVtoVtheVhospitalVafterVexperiencingVaVtonicVclonicVse
izureVisVscheduledVforVaVroutineVelectroencephalogramV(EEG).VInVpreparingVth
eVclientVforVtheVEEG,VtheVnurseVshouldVexplainVthatVtheVclientVwillVundergoV
whichVofVtheVfollowing?