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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct answer: B
Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.
2. A healthcare professional is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information?
- A. Disease registry.
- B. Department of Health.
- C. Bureau of Vital Statistics.
- D. Census data.
Correct answer: C
Rationale: The Bureau of Vital Statistics collects data on births and deaths, including infant mortality rates. This data is crucial for healthcare professionals to analyze and compare rates between different regions.
3. A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
- A. Refuses to eat her favorite meals at home.
- B. Drinks more soft drinks than previously.
- C. Voids only one or two times per day.
- D. Gained 10 pounds within one month.
Correct answer: B
Rationale: The correct answer is B. Increased thirst and fluid intake, such as drinking more soft drinks than previously, is a common symptom of diabetes mellitus in children. This increased thirst is due to the body trying to eliminate excess sugar through urination, leading to dehydration and the need for more fluids. The other choices are less likely to be directly related to the diagnosis of diabetes mellitus in this scenario.
4. A client is undergoing chemotherapy and is at risk for developing thrombocytopenia. What precaution should the nurse teach the client to minimize the risk of bleeding?
- A. Use a soft-bristled toothbrush.
- B. Engage in daily aerobic exercise.
- C. Take aspirin for headaches.
- D. Use an electric razor for shaving.
Correct answer: A
Rationale: Using a soft-bristled toothbrush is essential for clients at risk of thrombocytopenia to prevent gum bleeding, as their platelet counts may be low. Vigorous brushing with a hard-bristled toothbrush can injure the gums, leading to bleeding, which can be exacerbated in clients with low platelets. Therefore, advising the client to use a soft-bristled toothbrush is a crucial precaution to minimize the risk of bleeding.
5. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?
- A. 4+ pitting edema of both lower extremities.
- B. A Braden risk assessment scale rating score of ten.
- C. Warm, dry skin with a fever of 100° F.
- D. Hypoactive bowel sounds with infrequent bowel movements.
Correct answer: B
Rationale: A low Braden score indicates a high risk for pressure ulcers, making regular turning crucial to prevent skin breakdown.
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