MED SURG EXAM 3 ATI PRACTICE QUESTIONS W/
RATIONALES EXAM QUESTIONS AND ANSWERS
100% CORRECT!!!!
,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 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
RATIONALES EXAM QUESTIONS AND ANSWERS
100% CORRECT!!!!
,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 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
