2019 ATI MED-SURG PROCTORED FINAL EXAM .

2019 ATI MED-SURG PROCTORED FINAL EXAM . Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider. 137.. A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? Impaired sense of humor Explanation For The Answer A client who had a stroke involving the left cerebral hemisphere is likely to have language deficits, which include difficult using or comprehending language and difficulty writing. The nurse should expect a client who had a stroke involving the right cerebral hemisphere to have an impaired sense of humor. 138..A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? The client's bladder becomes distended. Explanation For The Answer Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face. 139.. A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? Check the results of the client's most recent CBC. Explanation For The Answer The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher. CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM 2019 ATI MED-SURG PROCTORED FINAL EXAM . 140.. A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? The purpose of this device is to immobilize the cervical spine. Explanation For The Answer A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks. 141..A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? Ability to self-feed with the use of adaptive equipment Explanation For The Answer A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation goal for the client is the ability to feed himself with the use of adaptive equipment. 142..A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Incorrect. Furnish restraints at the bedside. 143..A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? Place suction equipment at the client's bedside. Explanation For The Answer CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM CLASSROOM 2019 ATI MED-SURG PROCTORED FINAL EXAM . Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client. 144..A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? Place the client in a high-Fowler's position. Explanation For The Answer The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse’s initial action should be to place the client in a high-Fowler’s position to assist in providing immediate reduction in blood pressure and intracranial pressure 145..A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.) Grooming Long-term memory Incorrect. Support systems Affect Incorrect. Presence of pain 146..A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? Assess the cranial nerves. Explanation For The Answer The greatest risk to the client is from increased intracranial pressure (ICP) which may lead to herniation of the brain and death. The nurse should perform