ATI Med Surg Practice A 2023 with
rationales
A nurse is reinforcing teaching with a client who has mitral valve disease. Which of following statements
by the client indicates an understanding of the disease process?
A. "I should call my doctor if I get a headache."
B. "I might develop gastric reflux."
C. "I might develop excessive bruising."
D. "I should call my doctor if my ankles swell."
D. "I should call my doctor if my ankles swell."
RAT: Swelling of the ankles can indicate heart failure. The client should report this finding to the
provider.
-A provider might prescribe anticoagulants to prevent thrombus formation on the valve, which can
cause excessive bruising for a client who has mitral valve disease. However, excessive bruising is not a
direct result of the disease.
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of
rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
A. Apply cold packs to the inflamed joints.
B. Participate in high-impact exercise.
C. Carry a hand purse rather than a shoulder bag.
D. Sleep on a soft foam mattress.
A. Apply cold packs to the inflamed joints.
RAT: The nurse should instruct the client to use both warm and cold packs on inflamed joints to
decrease pain.
A nurse is collecting data from who has hypothyroidism. Which of the following manifestations should
the nurse anticipate?
A. Blurred vision
B. Insomnia
C. Bradycardia
D. Weight loss
C. Bradycardia
-The nurse should identify that blurred vision is a manifestation of hyperthyroidism
,-The nurse should identify that insomnia is a manifestation of hyperthyroidism that is caused by an
increase in the client's metabolic rate.
-The nurse should identify that weight loss is a manifestation of hyperthyroidism caused by an increase
in the client's metabolic rate.
RAT: The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a
decrease in the client's metabolic rate.
A nurse is reinforcing teaching with an adolescent child regarding testicular self-examination. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I will perform the exam before I shower."
B. "I will check my testicles every 6 months."
C. "I understand that testicular cancer is typically painless."
D. "I understand that pea-sized lumps are normal."
C. "I understand that testicular cancer is typically painless."
RAT: Clients should report a lump that is not painful because testicular cancer is typically painless.
Clients should perform a testicular self-examination after a warm shower. Clients should perform a
testicular self-examination monthly.
A nurse is contributing to the plan of care of a client who is at risk for osteoporosis. Which of the
following interventions should the nurse include to prevent bone loss?
A. Increase fluid intake.
B. Encourage range-of-motion exercises.
C. Massage bony prominences.
D. Encourage weight-bearing exercises.
D. Encourage weight-bearing exercises.
Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization,
thus helping to prevent osteoporosis.
-Fluid intake is beneficial for general health and wellness, and it helps to treat some disorders. Caffeine
and alcohol intake can increase the client's risk for developing osteoporosis. However, fluid intake does
not prevent bone loss.
-Range-of-motion exercises are beneficial for general health and wellness, and they help to maintain
flexibility and prevent contractures. However, range-of-motion exercises do not prevent bone loss.
-Massaging bony prominences should be avoided because it can traumatize deep tissues.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following instructions should the nurse include in the teaching?
,A. Increase intake of fiber-rich foods.
B. Take a laxative every morning.
C. Maintain a fluid intake of 1,200 mL/day.
D. Limit activity to preserve energy.
A. Increase intake of fiber-rich foods.
RAT: The nurse should instruct the client to increase the amount of fiber-rich foods in their diet. Dried
beans and brown rice are examples of fiber-rich foods. The nurse should instruct the client to increase
activity to stimulate the evacuation of stool.
-The nurse should instruct the client to initially take a laxative in the evening to stimulate the evacuation
of stool. However, the nurse should instruct the client to use laxatives sparingly.
-The nurse should instruct the client to increase their fluid intake to 2,000 mL/day to maintain soft
stools.
-The nurse should instruct the client to increase activity to stimulate the evacuation of stool.
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral
vascular disease. Which of the following statements indicates that the client is adhering to the nurse's
instructions?
A. "I apply rubbing alcohol to my feet every day to prevent infection."
B. "I will wear clean, knee-high wool socks every day to help improve my circulation."
C. "I use hot water bottles to keep my feet warm at night."
D. "I don't cross my legs anymore."
D. "I don't cross my legs anymore."
RAT: Clients who have peripheral vascular disease should not cross their legs because it can impede
circulation.
A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
A. Lower the side rails of the client's bed.
B. Apply wrist restraints to the client.
C. Position the client in the semi-Fowler's position.
D. Loosen clothing around the client's neck.
D. Loosen clothing around the client's neck.
RAT: The nurse should loosen clothing around the client's neck to maintain an open airway and prevent
aspiration.
, A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of
impending death. Which of the following manifestations should the nurse include?
A. Incontinence of bowel and bladder
B. Increase in heart rate
C. Warmness of the skin
D. Hypertension
A. Incontinence of bowel and bladder
RAT: The nurse should inform the caregiver that incontinence of the bowel and bladder is a
manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness,
and coolness of the skin.
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin
cancer. Which of the following information should the nurse include in the teaching?
A. Mohs surgery is a horizontal shaving of thin layers of the tumor.
Mohs surgery uses liquid nitrogen to destroy the cancerous tissue.
Mohs surgery is the preferred treatment for melanoma skin cancer.
Mohs surgery is a palliative treatment for metastatic skin cancer.
A. Mohs surgery is a horizontal shaving of thin layers of the tumor.
RAT: Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which
involves a horizontal shaving of thin layers of a tumor, has a high success rate.
-Cryosurgery, rather than Mohs surgery, uses liquid nitrogen to destroy cancerous tissue.
-Mohs surgery is the preferred treatment for basal and squamous cell carcinoma. The preferred
treatment for melanoma is a wide, full thickness surgical excision.
-Radiation, rather than Mohs surgery, can be used as a palliative treatment for metastatic skin cancer.
A nurse is assisting in the plan of care for a client who has had a recent left hemispheric stroke. Which of
the following actions should the nurse include in the plan?
Observe for impulsive behavior.
Approach the client from the right side.
Use simple verbal cues when directing tasks.
Place the client in low-Fowler's position during meals.
Use simple verbal cues when directing tasks.
RAT: The nurse should expect a client who had a left hemispheric stroke to manifest some degree of
expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding
rationales
A nurse is reinforcing teaching with a client who has mitral valve disease. Which of following statements
by the client indicates an understanding of the disease process?
A. "I should call my doctor if I get a headache."
B. "I might develop gastric reflux."
C. "I might develop excessive bruising."
D. "I should call my doctor if my ankles swell."
D. "I should call my doctor if my ankles swell."
RAT: Swelling of the ankles can indicate heart failure. The client should report this finding to the
provider.
-A provider might prescribe anticoagulants to prevent thrombus formation on the valve, which can
cause excessive bruising for a client who has mitral valve disease. However, excessive bruising is not a
direct result of the disease.
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of
rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
A. Apply cold packs to the inflamed joints.
B. Participate in high-impact exercise.
C. Carry a hand purse rather than a shoulder bag.
D. Sleep on a soft foam mattress.
A. Apply cold packs to the inflamed joints.
RAT: The nurse should instruct the client to use both warm and cold packs on inflamed joints to
decrease pain.
A nurse is collecting data from who has hypothyroidism. Which of the following manifestations should
the nurse anticipate?
A. Blurred vision
B. Insomnia
C. Bradycardia
D. Weight loss
C. Bradycardia
-The nurse should identify that blurred vision is a manifestation of hyperthyroidism
,-The nurse should identify that insomnia is a manifestation of hyperthyroidism that is caused by an
increase in the client's metabolic rate.
-The nurse should identify that weight loss is a manifestation of hyperthyroidism caused by an increase
in the client's metabolic rate.
RAT: The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a
decrease in the client's metabolic rate.
A nurse is reinforcing teaching with an adolescent child regarding testicular self-examination. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I will perform the exam before I shower."
B. "I will check my testicles every 6 months."
C. "I understand that testicular cancer is typically painless."
D. "I understand that pea-sized lumps are normal."
C. "I understand that testicular cancer is typically painless."
RAT: Clients should report a lump that is not painful because testicular cancer is typically painless.
Clients should perform a testicular self-examination after a warm shower. Clients should perform a
testicular self-examination monthly.
A nurse is contributing to the plan of care of a client who is at risk for osteoporosis. Which of the
following interventions should the nurse include to prevent bone loss?
A. Increase fluid intake.
B. Encourage range-of-motion exercises.
C. Massage bony prominences.
D. Encourage weight-bearing exercises.
D. Encourage weight-bearing exercises.
Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization,
thus helping to prevent osteoporosis.
-Fluid intake is beneficial for general health and wellness, and it helps to treat some disorders. Caffeine
and alcohol intake can increase the client's risk for developing osteoporosis. However, fluid intake does
not prevent bone loss.
-Range-of-motion exercises are beneficial for general health and wellness, and they help to maintain
flexibility and prevent contractures. However, range-of-motion exercises do not prevent bone loss.
-Massaging bony prominences should be avoided because it can traumatize deep tissues.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following instructions should the nurse include in the teaching?
,A. Increase intake of fiber-rich foods.
B. Take a laxative every morning.
C. Maintain a fluid intake of 1,200 mL/day.
D. Limit activity to preserve energy.
A. Increase intake of fiber-rich foods.
RAT: The nurse should instruct the client to increase the amount of fiber-rich foods in their diet. Dried
beans and brown rice are examples of fiber-rich foods. The nurse should instruct the client to increase
activity to stimulate the evacuation of stool.
-The nurse should instruct the client to initially take a laxative in the evening to stimulate the evacuation
of stool. However, the nurse should instruct the client to use laxatives sparingly.
-The nurse should instruct the client to increase their fluid intake to 2,000 mL/day to maintain soft
stools.
-The nurse should instruct the client to increase activity to stimulate the evacuation of stool.
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral
vascular disease. Which of the following statements indicates that the client is adhering to the nurse's
instructions?
A. "I apply rubbing alcohol to my feet every day to prevent infection."
B. "I will wear clean, knee-high wool socks every day to help improve my circulation."
C. "I use hot water bottles to keep my feet warm at night."
D. "I don't cross my legs anymore."
D. "I don't cross my legs anymore."
RAT: Clients who have peripheral vascular disease should not cross their legs because it can impede
circulation.
A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
A. Lower the side rails of the client's bed.
B. Apply wrist restraints to the client.
C. Position the client in the semi-Fowler's position.
D. Loosen clothing around the client's neck.
D. Loosen clothing around the client's neck.
RAT: The nurse should loosen clothing around the client's neck to maintain an open airway and prevent
aspiration.
, A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of
impending death. Which of the following manifestations should the nurse include?
A. Incontinence of bowel and bladder
B. Increase in heart rate
C. Warmness of the skin
D. Hypertension
A. Incontinence of bowel and bladder
RAT: The nurse should inform the caregiver that incontinence of the bowel and bladder is a
manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness,
and coolness of the skin.
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin
cancer. Which of the following information should the nurse include in the teaching?
A. Mohs surgery is a horizontal shaving of thin layers of the tumor.
Mohs surgery uses liquid nitrogen to destroy the cancerous tissue.
Mohs surgery is the preferred treatment for melanoma skin cancer.
Mohs surgery is a palliative treatment for metastatic skin cancer.
A. Mohs surgery is a horizontal shaving of thin layers of the tumor.
RAT: Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which
involves a horizontal shaving of thin layers of a tumor, has a high success rate.
-Cryosurgery, rather than Mohs surgery, uses liquid nitrogen to destroy cancerous tissue.
-Mohs surgery is the preferred treatment for basal and squamous cell carcinoma. The preferred
treatment for melanoma is a wide, full thickness surgical excision.
-Radiation, rather than Mohs surgery, can be used as a palliative treatment for metastatic skin cancer.
A nurse is assisting in the plan of care for a client who has had a recent left hemispheric stroke. Which of
the following actions should the nurse include in the plan?
Observe for impulsive behavior.
Approach the client from the right side.
Use simple verbal cues when directing tasks.
Place the client in low-Fowler's position during meals.
Use simple verbal cues when directing tasks.
RAT: The nurse should expect a client who had a left hemispheric stroke to manifest some degree of
expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding
