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Ati rn adult medical surgical 2023
Total Questions : 100
Showing 10 questions, Sign in for moreA nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?
Client comes to the ED reporting a headache that has lasted for 3 days. Reports pain is currently a 7 out of 10. Client appears pale and lethargic. Client also reports photophobia, malaise, nausea, and chills. Positive nuchal rigidity, lung sounds clear, heart sounds regular, hyperactive bowel sounds in all 4 quadrants. 18-gauge IV Initiated in the left antecubital space and IV fluids started. Awaiting CT scan results.
- Temperature 39.2° C (102.6° F)
- Heart rate 115/min
- Respiratory rate 12/min
- Blood pressure 98/64 mm Hg
- Oxygen saturation 94% on room air
A nurse is caring for a client who has just been admitted to the emergency department (ED).
Explanation
Rationale for Correct Choices:
- Meningitis: Meningitis is an infection of the meninges which presents with headache, fever, nuchal rigidity, and photophobia, all of which the client has. The additional symptoms of malaise and lethargy also suggest meningitis.
- Decrease environmental stimuli: Decreasing environmental stimuli is crucial in managing meningitis, particularly when the patient has photophobia and a headache. Minimizing light, noise, and other stressors will help reduce discomfort, especially in the early stages of the infection.
- Initiate neurological checks every 2 hr: Neurological checks every 2 hours are essential to monitor the client for signs of worsening intracranial pressure or neurological deterioration, allowing early identification of any changes in mental status, consciousness, or motor function, enabling timely interventions.
- Temperature: Fever is a hallmark sign of meningitis, and monitoring the temperature will guide treatment effectiveness. A persistent high fever could indicate that the infection is progressing or that the treatment is not sufficient.
- Lactate: Elevated lactate levels could suggest poor tissue perfusion or sepsis, which can develop as a complication of meningitis. Monitoring lactate is crucial to assess for systemic involvement, and higher lactate levels may prompt quicker intervention to prevent further complications such as shock.
Rationale for Incorrect Choices:
- Septic shock: Septic shock typically involves severe hypotension, organ failure, and marked deterioration in condition, which are not evident at this stage. The current presentation aligns more with meningitis.
- Hydrocephalus: Hydrocephalus, characterized by excess cerebrospinal fluid, often causes headaches and lethargy but does not typically present with fever, nuchal rigidity, or photophobia. These are specific signs of meningitis, making this diagnosis less likely.
- Migraine headache: While migraines can cause headaches, nausea, and photophobia, they do not typically result in fever or nuchal rigidity, which are common symptoms of meningitis. Additionally, the patient’s lethargy and malaise are inconsistent with migraines.
- Administer gabapentin: Gabapentin is primarily used for neuropathic pain or seizures, not for infections like meningitis. The patient’s symptoms suggest an infection, and the priority is to start antimicrobial therapy to address the underlying cause.
- Prepare the client for surgery: Surgery is not typically required in the immediate management of meningitis unless there is a complication like an abscess. The priority at this stage is diagnosing the infection and starting appropriate antimicrobial therapy, not surgery.
- Administer Sumatriptan: Sumatriptan is a medication for treating acute migraine headaches, which the patient does not appear to have. The client’s symptoms, including fever, nuchal rigidity, and photophobia, suggest an infectious process rather than a primary headache disorder.
- Vascular changes: Monitoring vascular changes is not a primary concern in meningitis unless the patient is showing signs of septic shock or severe sepsis. At this stage, the more immediate parameters to monitor are temperature and lactate levels, which can directly indicate the progression of infection or sepsis.
- Gait: Gait issues are not directly associated with meningitis unless there is significant neurological involvement. Gait would be more relevant to monitor in conditions like strokes or neurological disorders affecting motor coordination.
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
A nurse is caring for a client who had a thoracentesis 2 hr ago. Which of the following findings should the nurse expect?
A nurse is caring for a client receiving total parenteral nutrition who weighs 160 lb. If the RDA of protein is 0.8 g/kg of body weight, how many grams of protein should the client receive daily? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Calculation:
- Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 160 lb / 2.2 lb/kg
= 72.7272... kg.
- Calculate the total daily protein in grams (g).
Total daily protein (g) = RDA (g/kg) × Weight (kg)
= 0.8 g/kg × 72.7272... kg
= 58.1818... g.
- Round the answer to the nearest whole number.
= 58 g.
Answer: 58 g
A home health nurse is assessing a client who has COPD. Which of the following findings indicates the need for a referral for pulmonary rehabilitation?
A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take?
A nurse is planning to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse plan to take?
A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
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