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Med surg exam 3 ATI practice questions w/ rationales questions and answers graded A+ 2024/2025
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Med surg exam 3 ATI practice questions w/ rationales questions and answers graded A+ 2024/2025
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Med surg exam 3 ATI practicequestions w/ rationales
Rationale: expressive aphasia consequences from damage to a place of the frontal lobe and
is a motor speech problem. The consumer who has expressive aphasia is able to
understand what's unhappy, however is not able to speak verbally. However, this does not
necessarily mean that a client is unable to reliably document ache. Proof based exercise
suggests the nurse ought to first try to acquire the patron self document of ache. When
assessing a customer for ache, the nurse have to utilize the hierarchy of pain measures
which begins with self report. It is continually higher to use a subjective approach, together
with a consumer document, as opposed to an goal technique, consisting of some thing this
is observable via the nurse, that's a good deal less dependable.
A nurse is assessing a consumer who has a concussion from a sports injury. Which of the
subsequent manifestations have to the nurse count on? - ANSSensitivity to light
Rationale: the nurse have to anticipate a consumer who has a slight disturbing brain harm,
inclusive of a concussion, to have sensitivity to mild and noise
A nurse is being concerned for a client who has aphasia following a stroke. A member of the
family asks the nurse how she need to speak with the customer. Which of the following
responses by using the nurse is appropriate? - ANSIncorporate nonverbal cues inside the
conversation
Rationale: nonverbal cues, decorate the client's potential to realise and use language
A nurse is worrying for a client who has Parkinson's ailment and is taking diphenhydramine
25 mg PO TID. Which of the following healing outcome must the nurse expect to see? -
ANSDecreased tremors
Rationale: Clients who've Parkinson's ailment regularly revel in trembling, muscle stress,
difficulty walking and troubles with balance and coordination. Antihistamines, like
diphenhydramine, have a moderate anticholinergic effect and may be helpful in controlling
tremors in the early stage of the ailment.
A nurse is worrying for a purchaser who is subconscious following a cerebral hemorrhage.
Which of the following nursing interventions is of highest precedence? - ANSSuction saliva
from the clients mouth
Rationale: the unconscious patron is unable to independently hold a clear airway and is at
danger for useless airway clearance according to the protection and threat reduction priority
placing framework, maintaining the clients airway, breathing, and move is the best
precedence
,Patient admitted with a likely analysis of infective endocarditis and prescribed gentamicin.
Client is exhibiting signs and symptoms of headache, dizziness, nausea and tinnitus. Client's
diagnostic lab wailers additionally indicated an increase in BUN, creatinine, gentamicin top
stage, AST/ALT. - ANSThe nurse have to perceive that the priority hypothesis is that the
finest hazard for the patron is developing hearing loss due to antibiotics. Ototoxicity may also
arise in customers who're receiving aminoglycosides, such as gentamicin. An increase in
BUN, creatinine, gentamicin top degree, ALT/AST all location the client at danger for
ototoxicity and listening to loss. Hearing loss is normally inside the excessive frequency
variety and is associated with top aminoglycoside stages that preserve to remain extended.
A nurse is caring for a consumer following cataract surgical procedure. Which of the
subsequent comments from the customer need to the nurse record to the customers issuer?
- ANS"I want something for the pain in my eye. I can not stand it"
Rationale: following cataract surgical operation, the consumer ought to anticipate most
effective slight ache and ought to right now report any pain, lower in imaginative and
prescient, or boom in discharge from the attention. Severe eye pain after surgery may
suggest multiplied intraocular stress or hemorrhage.
A nurse is assessing a patron who has a spinal twine harm. Which of the following action
should the nurse take to monitor C4 feature? - ANSApply downward pressure even as the
purchaser shrugs their shoulders upward
Rationale: this evaluation monitors the motor characteristic of C4 to C5
A nurse is planning take care of a client who had a disturbing brain harm and is rising
restlessly from a coma. Which of the following intervention ought to the nurse consist of in
the plan? - ANSReduce stimuli
Rationale: the nurse need to lessen stimuli by means of lowering the quantity of traffic,
talking frivolously, and creating a quiet environment
A nurse is worrying for a customer who has had a spinal twine damage at the extent of the
T2-T3 vertebra. When making plans care, the nurse assume which of the following sorts of
disability? - ANSParaplegia
Rationale: Paraplegia or paralysis of each legs, is visible after a SCI underneath T1
A nurse is worrying for a consumer 4 hours following evacuation of a subdural hematoma.
Which of the following assessment is the nurses priority? - ANSRespiratory status
Rationale: When the usage of the airway, respiration,
move approach to consumer care, the nurse ought to vicinity the priority on assessing the
consumer's respirations, noting the price and sample and evaluating arterial blood gases.
Following intercranial surgical procedure, even mild hypoxia can get worse cerebral
ischemia.
, A nurse is caring for an older adult patron who has dementia and handles anxiety by
confabulating. The nurse must understand confabulation whilst the customer .. - ANSMakes
up stories when he is not able to remember real activities
Rationale: Confabulating is filling in gaps in memory through fabrication. A client who has
dementia may additionally do this unconsciously to cover for and reduce tension about
memory gaps.
A nurse is enhancing the food plan of a patron who has Parkinson's disease and is
prescribed selegiline, an MAOI. Which of the following foods should the nurse dispose of? -
ANSCheddar cheese
Rationale: the nurse must do away with aged cheeses from the weight-reduction plan of a
consumer who's prescribed selegiline. Cheddar cheese includes tyramine, that can cause a
hypertensive crisis.
A nurse is assessing a customer who has meningitis. Which of the following findings should
the nurse expect? - ANSSevere headache
Rationale: the nurse should expect a purchaser who has meningitis to show up a excessive
headache due to meningeal infection.
A nurse is worrying for a consumer who has had a stroke involving the right hemisphere.
Which of the subsequent changes in characteristic must the nurse assume? - ANSInability to
recognize his circle of relatives participants
Rationale: the right hemisphere is worried with visible and spatial focus. A patron who's
unable to apprehend faces might have involvement with the proper hemisphere.
A nurse is caring for a 24 yr antique customer who reports a recent fall, hitting their head and
right shoulder after slipping on a moist floor the day prior to this. Denies LOC. Complains of
ache in right shoulder. Has taken both acetaminophen and ibuprofen for ache with minimum
relief acquired. Stayed up whole night playing video video games the day before today to
distract self from ache. Reports intermittent nausea and vomiting.
Nurse's notes (0900): reviews pain in proper shoulder. Limited ROM notes. Rates ache 7/10.
Denies numbness and tingling in arm. No swelling or bruising over the shoulder. Fingers
warm with Cap fill up much less than 3 seconds, sensation intact. Drowsy. Oriented to man
or woman, vicinity, and time. Irritable and restless at instances. PERRLA. GCS of 15. No
hematomas mentioned on head. No N/V this time.
One thousand: continues to document ache in proper shoulder. Pain accelerated from 7 to
an 8/10. Increased drowsiness cited. GCS unchanged.
Vital symptoms: - ANSThe nurse need to first address the customer's drowsiness
accompanied by means of the customer's right shoulder pain.
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