Exam (elaborations)
ATI - Medical-Surgical Musculoskeletal, Gastrointestinal, Immune and Infectious
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ATI - Medical-Surgical Musculoskeletal, Gastrointestinal, Immune and Infectious
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ATI - Medical-Surgical: Musculoskeletal, Gastrointestinal, Immune andInfectious
1. A nurse is planning discharge teaching for a client who has systemic lupus
erythematous (SLE). Which of the following instructions should the nurse
plan to include?
A. "Avoid the use of NSAIDs."
B. "Stop taking the corticosteroids when your symptoms resolve."
C. "Exposure to ultraviolet light will help control the skin rashes."
D. "Monitor your body temperature and report any elevations promptly.":
Monitor your body temperature and report any elevations promptly."
SLE is a chronic autoimmune disorder that can affect any organ of the body. With
SLE, the body's immune system becomes hyperactive, forming antibodies that
attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs,
and blood. SLE is characterized by periods of exacerbation and remissions. The
nurse should teach the client to monitor body temperature and report any elevations
promptly, as fever can suggest either an exacerbation or a potentially life-
threatening infection.
2. A nurse is caring for a client who has systemic lupus erythematosus (SLE)
and is concerned about skin lesions on the face and neck. The client asks the
nurse, "what should I do about these spots?" which of the following nursing
responses should the nurse give?
A. "Keep the lesions covered with a light sterile dressing when going out-
doors"
B. "There is not much you can do. The lesions will go away when your disease
is in remission"
C. "Apply moisturizer after bathing the lesions with warm water"
D. "Apply antibiotic cream twice a day until scabs form on the lesions": "Apply
moisturizer after bathing the lesions with warm water."
The nurse should instruct the client to clean, dry, and moisturize the skin using warm
(not hot) water, along with an unscented lotion.
3. A nurse is caring for a client who is 3 days postoperative following a right
total hip arthroplasty. While transferring to a chair, the client cries out in
pain. The nurse should assess the client for which of the following
manifestations of dislocation of the hip prosthesis?
, ATI - Medical-Surgical: Musculoskeletal, Gastrointestinal, Immune and
Infectious
A. Bulging in the area over the surgical incision
B. Shortening of the right leg
C. Sensation of warmth over the surgical incision
D. Pallor following elevation of the right leg: Shortening of the right leg
-----
The nurse should monitor the client for shortening of the affected leg as an indication
of dislocation of the prosthesis. Other findings include increased hip pain, inability
to move the extremity, and rotation of the hip internally or externally.
4. A nurse is caring for a client who has a pelvic fracture. The client reports
sudden shortness of breath, stabbing chest pain, and feelings of doom. The
nurse should identify that the client is experiencing which of the following
complications?
A. Pneumonia
B. Pulmonary embolus
C. Tension pneumothorax
D. Tuberculosis: Pulmonary embolus
-----
Immobility following musculoskeletal trauma places the client at an increased risk
for pulmonary embolus. The client might also exhibit tachycardia, chest petechiae,
and have a decreased SaO2. The nurse should notify the rapid response team
immediately.
5. A nurse is caring for a client who is in skeletal traction following a femur
fracture. The nurse finds the client has slid down toward the foot of the bed
and the traction weight is resting on the floor. Which of the following actions
should the nurse take?
A. Remove the weight temporarily to reposition the client to the correct
alignment in bed.
B. Have the client use a trapeze to pull himself up while ensuring the weight
hangs freely.
C. Lift the rope off the pulley while the client rocks back and forth to
reposition.D. Lift the weight manually while another staff member moves the
client up in bed.: Have the client use a trapeze to pull himself up while ensuring
the weight hangs freely.
-----
, ATI - Medical-Surgical: Musculoskeletal, Gastrointestinal, Immune and
Infectious
The nurse should ensure that traction weight is hanging freely. The client can use
an overhead trapeze bar to move up in bed, or the nurse can assist the client up,
making sure to maintain proper alignment of the extremity.
6. A nurse is providing preoperative teaching for a client who is scheduled for
total knee arthroplasty. Which of the following statements by the client should
the nurse identify as understanding of the teaching?
A. "I will wear a continuous movement machine on my knee for 24 hours a
day."
B. "I should avoid taking NSAID medications for pain after surgery."
C. "I should wear elastic stockings on both of my legs."
D. "I will begin exercising my legs the day after surgery.": "I should wear elastic
stockings on both of my legs."
------
The purpose of elastic stockings is to prevent venous thromboembolism, which is
a common complication following orthopedic surgery. Therefore, the nurse should
identify this statement as understanding of the teaching.
7. A nurse is discussing the difference between rheumatoid arthritis (RA) and
osteoarthritis with a newly licensed nurse. Which of the following information
should the nurse include about osteoarthritis?
A. "Osteoarthritis is caused by autoimmune processes."
B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate."
C. "Osteoarthritis affects other organ systems."
D. "Osteoarthritis can impair a joint on a single side of the body.":
"Osteoarthritis can impair a joint on a single side of the body."
------
The nurse should identify unilateral joint involvement as a finding of osteoarthritis.
A client who has RA experiences symmetrical joint impairment.
8. A nurse is assessing a client who is 24 hr postoperative following an above-
the-elbow amputation. Which of the following findings should the nurse
identify as the priority?
A. Report of muscle spasms
B. Inability to get dressed without assistance
, ATI - Medical-Surgical: Musculoskeletal, Gastrointestinal, Immune and
Infectious
C. Report of feelings of anger
D. Refusal to look at the affected limb: Report of muscle spasms
-----
The nurse should consider Maslow's hierarchy of needs, which includes five levels
of priority. The first level consists of physiological needs; the second level consists
of safety and security needs; the third level consists of love and belonging needs;
the fourth level consists of personal achievement and self-esteem needs; and the
fifth level consists of achieving full potential and the ability to problem solve and
cope with life situations. When applying Maslow's hierarchy of needs priority-
setting framework, the nurse should review physiological needs first. The nurse
should then address the client's needs by following the remaining four hierarchal
levels. It is important, however, for the nurse to consider all contributing client
factors, as higher levels of the pyramid can compete with those at the lower levels,
depending on the specific client situation. The fourth level of Maslow's hierarchy of
needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem
needs. Therefore, the nurse should identify the report of muscle spasms, a
physiological need, as the priority client finding.
9. A nurse in the emergency department is preparing to discharge a client
following a Grade II (moderate) ankle sprain. Which of the following
instructions should the nurse plan to give to the client?
A. Perform passive range-of-motion exercises of the ankle hourly.
B. Keep the affected extremity in a dependent position.
C. Wrap a loose dressing around the affected ankle.
D. Apply cold compresses to the extremity intermittently.: Apply cold
compresses to the extremity intermittently. ------
Cold minimizes swelling and erythema to the affected area. Therefore, the nurse
should instruct the client to apply cold compresses for no more than 20 min at a
time.
10. A nurse is teaching a client who has a new prescription for alendronate
for treatment of osteoporosis. Which of the following statements by the client
indicates understanding of the teaching?
A. "I will take the medication in the evening."
B. "I will drink a full glass of milk with the medication."
C. "I will take the medication at mealtime."
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