ATI Med-Surg (Multiple Response) 1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations INCORRECT 5) Bradycardia Answer Rationale: ...
ati med surg multiple response ati med surg multiple response 1 a nurse is collecting data from a client who has emphysema which of the following findings should the nurse expect select all th
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ATI Med-Surg (Multiple Response)
, ATI Med-Surg (Multiple Response)
1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the
nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen
exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm
becomes permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid,
and the ribs flare outward. This produces the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases
oxygenation. Clubbing results from these chronic low blood-oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity; consequently, respirations
become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less oxygen being
delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations
should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of cortisol or by
excessive use of corticosteroids. Buffalo hump, a collection of fat between the shoulders, is a common
manifestation of Cushing's syndrome.Purple striations is correct. Purple striations on the skin of the
abdomen, thighs, and breasts are a common manifestation of Cushing's syndrome. This is due to the collection
of body fat in these areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome.
,Clients who have this manifestation present with a round, red, full face.Tremors is incorrect. Tremors are not
a common finding of Cushing's syndrome.Obese extremities is incorrect. Clients who have Cushing's
syndrome have truncal obesity, a protuberant abdomen, with thin extremities, which is due to an alteration in
protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the
following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the
cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a hematoma at
the insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce
the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take
hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the
teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
INCORRECT
3) Relaxing skeletal muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective antianxiety agent and
is used to decrease anxiety in surgical clients as well as in persons with moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine is an effective antiemetic and is
used to control nausea and vomiting in pre- and postoperative clients.
, Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as diazepam
(Valium), are used to produce skeletal muscle relaxation.
Preventing surgical site infections is incorrect. The nurse should instruct the client that antibiotics
administered prior to surgery are used to diminish the risk of surgical site infections; hydroxyzine, an
antiemetic, does not have any effect on bacteria.
Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the effects of
narcotic pain medications. The nurse should instruct the client that when it is used for surgical clients, narcotic
requirements may be significantly reduced.
5. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that
teaching has been effective when the client identifies which of the following manifestations of hypoglycemia?
(Select all that apply.)
Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors, anxiety, irritability,
headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety, irritability,
headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety, irritability, headache,
and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
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