ATI PN Med Surg Proctored
Exam 2023 ,
75 pag.
, NURSING LP N 100 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
, NURSING LP N 100 ATI Med-Surg
(Multiple Response
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
, NURSING LP N 100 ATI Med-Surg
(Multiple Response
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
Exam 2023 ,
75 pag.
, NURSING LP N 100 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
, NURSING LP N 100 ATI Med-Surg
(Multiple Response
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
, NURSING LP N 100 ATI Med-Surg
(Multiple Response
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
