ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
- A. Confusion
- B. Weakness
- C. Increased intracranial pressure
- D. Increased urinary output
Correct answer: Weakness
Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.
2. A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take?
- A. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice
- B. Tell staff to explain procedures to clients before obtaining informed consent
- C. Instruct unit staff to share personal experiences to help clients make decisions
- D. Develop a system for staff members to report safety concerns in the client care environment
Correct answer: D
Rationale: The correct answer is D. Developing a system for staff members to report safety concerns in the client care environment is crucial to promoting client advocacy and ensuring client safety. This action empowers staff to identify and address potential safety issues, ultimately enhancing the quality of care provided. Choices A, B, and C are incorrect. Choice A suggests implementing paternalism, which involves making decisions for clients without their input, contradicting the principles of client advocacy. Choice B focuses on informed consent procedures, which are important but do not directly relate to promoting client advocacy among staff. Choice C, sharing personal experiences, may not always align with professional boundaries and can potentially bias clients' decision-making processes.
3. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?
- A. Avoid prolonged exposure to sunlight.
- B. Take this medication with a meal.
- C. Increase your intake of potassium-rich foods.
- D. Limit your fluid intake to 1 liter per day.
Correct answer: C
Rationale: The correct instruction for a client taking furosemide is to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss, so increasing potassium-rich foods helps prevent hypokalemia. Choice A, avoiding prolonged exposure to sunlight, is not directly related to furosemide use. Choice B, taking the medication with a meal, is not a specific requirement for furosemide administration. Choice D, limiting fluid intake to 1 liter per day, is not the correct advice as furosemide is a diuretic that often requires increased fluid intake to prevent dehydration.
4. A patient with a history of cardiovascular disease is prescribed hormone replacement therapy (HRT). What should the nurse emphasize regarding the long-term risks associated with HRT?
- A. HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke.
- B. HRT may decrease the risk of osteoporosis.
- C. HRT may improve mood and energy levels.
- D. HRT may increase the risk of breast cancer.
Correct answer: A
Rationale: HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke, particularly in patients with a history of cardiovascular disease.
5. What term refers to the degree of myocardial fiber stretch before contraction, related to the volume of blood distending the ventricles at the end of diastole, and determined by the amount of venous return?
- A. Preload
- B. Afterload
- C. Contractility
- D. Ejection fraction
Correct answer: A
Rationale: The correct answer is A: Preload. Preload is the degree of myocardial fiber stretch before contraction, influenced by the volume of blood returning to the heart. This parameter is related to the amount of blood in the ventricles at the end of diastole. Choice B, Afterload, refers to the pressure or resistance that the ventricles must overcome to eject blood. Choice C, Contractility, is the intrinsic ability of the heart muscle to contract. Choice D, Ejection fraction, is the percentage of blood pumped out of the ventricles with each contraction.
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