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Ati rn adult medical surgical 2023 exam
Total Questions : 88
Showing 10 questions, Sign in for moreClient reports to ED with dyspnea. Reports weight gain and abdominal distention, increasing over past 2 days.
Sinus tachycardia; client denies chest pain.
Respirations labored, crackles on auscultation. Client unable to breathe in supine position. Head of bed at 45°. Supplemental oxygen at 2 L/min via nasal cannula.
Abdomen distended with dilated veins and protruding umbilicus. Hepatomegaly present. Hypoactive bowel sounds x4 quadrants. Denies abdominal pain, melena, diarrhea, nausea/vomiting.
Peripheral pitting edema.
A nurse in an emergency department (ED) is caring for a client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for Correct Choices:
- Cirrhosis: The client's symptoms—dyspnea, abdominal distention, hepatomegaly, peripheral edema, dilated abdominal veins, and ascites—are classic findings of decompensated cirrhosis. The presence of respiratory difficulty and positional breathing, combined with hypoactive bowel sounds and fluid accumulation, further supports this diagnosis.
- Measure the abdominal girth: This is key to track the progression or improvement of ascites. Regular monitoring allows for early detection of fluid accumulation, evaluation of treatment effectiveness, and aids in decisions about diuretic therapy or paracentesis.
- Teach the client about restricted sodium intake: Sodium promotes fluid retention, worsening ascites and edema. Educating the client about dietary sodium limits is critical in managing cirrhosis and preventing further complications from fluid overload.
- Ascites: Monitoring for ascites provides immediate clinical feedback on the severity of fluid overload and response to interventions like diuretics or sodium restriction. It is an essential parameter in managing liver failure.
- Ammonia levels: Elevated ammonia in cirrhosis is linked to hepatic encephalopathy. Monitoring this helps detect early neurological changes and allows for timely treatment with medications like lactulose to prevent cognitive deterioration.
Rationale for Incorrect Choices:
- Crohn’s disease: While it involves gastrointestinal symptoms, Crohn's typically presents with abdominal pain, diarrhea, and weight loss, not massive ascites or hepatomegaly. The client’s signs more strongly align with liver dysfunction than inflammatory bowel disease.
- Celiac disease: This autoimmune disorder is associated with gluten sensitivity, malabsorption, and often weight loss or nutrient deficiencies—not the significant fluid retention, edema, or liver-related symptoms shown in this scenario.
- Pancreatitis: Pancreatitis may present with abdominal pain and elevated pancreatic enzymes, but it doesn't cause peripheral edema, hepatomegaly, or large-volume ascites. The absence of abdominal pain and the presence of other findings disqualify this diagnosis.
- Assess amylase and lipase levels: These are useful in diagnosing pancreatitis but are not relevant in the setting of cirrhosis. The client has no signs of pancreatic inflammation or acute abdominal pain that would justify these tests.
- Manage pain control: Pain is not a reported symptom in this case. While pain management is important in general care, it is not a priority in this clinical scenario where respiratory distress and fluid management are more urgent.
- Teach the client about gluten: Gluten restriction is specific to managing celiac disease, which is not supported by this client’s presentation. There is no evidence of gluten sensitivity, diarrhea, or malabsorption issues in this case.
- Unintentional weight loss: This would be expected in conditions with malnutrition or wasting, not in cases with fluid retention like cirrhosis. The client has gained weight, likely due to ascites and edema.
- Diet adherence to prevent exacerbations: Although general dietary adherence is important in chronic disease management, it is not specific or measurable enough in this acute care scenario. Specifically monitoring the impact of the diet (e.g., through changes in ascites or edema) is more direct.
A nurse is teaching a client about the manifestations of menopause. Which of the following findings should the nurse include?
HIV type 1 (HIV-1)
Client diagnosed with HIV-1 3 months ago. Returns to clinic today for follow-up visit and to discuss recent laboratory findings.
Upon diagnosis:
WBC count 4,500/mm3 (5,000 to 10,000/mm3)
Platelets 164,000/mm3 (150,000 to 400,000/mm3)
Sodium 139 mEq/L (136 to 145 mEq/L)
Potassium 4.2 mEq/L (3.5 to 5 mEq/L)
BUN 16 mg/dL (10 to 20 mg/dL)
3-month visit:
WBC count 4,100/mm3 (5,000 to 10,000/mm3)
Platelets 162,000 mm3 (150,000 to 400,000/mm3)
Sodium 139 mEq/L (136 to 145 mEq/L)
Potassium 3.8 mEq/L (3.5 to 5 mEq/L)
BUN 18 mg/dL (10 to 20 mg/dL)
A nurse in a health clinic is caring for a client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
Explanation
Rationale for Correct Choices:
- Infection: A low WBC count of 4,100/mm³ indicates a suppressed immune system, which is a complication in HIV. White blood cells play a key role in fighting infections, so a drop below the normal range places the client at increased risk for opportunistic and routine infections.
- WBC count: The client's WBC count has declined from 4,500/mm³ at diagnosis to 4,100/mm³, now falling below the standard range of 5,000–10,000/mm³. This trend suggests worsening immunosuppression, commonly seen in clients with HIV as the virus affects CD4+ T cells, reducing the body’s ability to fight infections.
Rationale for Incorrect Choices:
- Seizures: Seizure risk is usually associated with electrolyte imbalances, especially hyponatremia or hypernatremia. The client’s sodium level is 139 mEq/L, which is within the normal range, indicating that the risk for seizures is not elevated.
- Bleeding: Although the client’s platelet count has slightly decreased from 164,000 to 162,000/mm³, it remains within the normal range of 150,000–400,000/mm³. Significant bleeding risk generally arises when platelet levels fall well below 100,000/mm³.
- Dysrhythmias: The potassium level is 3.8 mEq/L, within the normal range of 3.5–5.0 mEq/L. Abnormal potassium levels, particularly hypo- or hyperkalemia, are key contributors to cardiac dysrhythmias, which are not suggested by the current lab values.
- Renal failure: The client’s BUN is 18 mg/dL, well within the normal range of 10–20 mg/dL. There is no elevation in BUN or signs of impaired kidney function, making renal failure an unlikely concern at this time.
- Platelet count: The platelet count is slightly lower than before but still within normal limits. A count of 162,000/mm³ does not pose a clinical concern for bleeding, and it does not indicate a serious hematologic issue requiring immediate intervention.
- Sodium level: The sodium level is 139 mEq/L, which is normal. It does not contribute to neurological symptoms such as seizures and is not associated with infection risk or other critical conditions in this scenario.
- Potassium level: The potassium level of 3.8 mEq/L is also within normal range. There is no evidence of potassium-related complications such as dysrhythmias or muscle weakness in the current context.
- BUN level: The client's BUN level is within the normal range (18 mg/dL), indicating normal kidney function and not a risk factor for any of the listed conditions.
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding?
A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
A nurse is reviewing a client's ECG rhythm strip. Which of the following components should the nurse use to measure impulse conduction from the sinus node through the atrioventricular node?
A nurse is caring for a client who is receiving phototherapy for psoriasis. Which of the following findings should the nurse identify as an indication of overexposure?
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