ATI LPN
ATI PN Adult Medical Surgical 2019
1. When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?
- A. Brudzinski's sign
- B. Positive Babinski reflex
- C. Kernig's sign
- D. Both A and C
Correct answer: D
Rationale: Both Brudzinski's sign and Kernig's sign are classic signs of meningeal irritation, commonly associated with meningitis. Brudzinski's sign is positive when flexing the neck causes involuntary flexion of the hips and knees due to irritation of the meninges. Kernig's sign is positive when there is pain and resistance with knee extension after hip flexion, indicating meningeal irritation or inflammation. The Babinski reflex, mentioned in choice B, is a test used to assess upper motor neuron damage and is not specific to meningitis. Therefore, choices A and C are the correct options as they are indicative of meningeal irritation in a suspected case of meningitis.
2. A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?
- A. Chorionic villus sampling under ultrasound.
- B. Amniocentesis and fetal monitoring.
- C. Ultrasonography and nonstress test.
- D. Oxytocin challenge test and fetal heart rate monitoring.
Correct answer: C
Rationale: A biophysical profile (BPP) is a prenatal test that assesses the well-being of the fetus. It typically includes ultrasonography to evaluate fetal movements, muscle tone, breathing movements, and amniotic fluid volume. Additionally, a nonstress test is performed to monitor the fetal heart rate in response to its movements. These tests help in determining the overall health and viability of the fetus, making them essential components of prenatal care for assessing fetal well-being.
3. A client with type 2 diabetes mellitus is prescribed metformin (Glucophage). Which instruction should the nurse provide?
- A. Take the medication on an empty stomach.
- B. Limit your fluid intake while on this medication.
- C. Monitor your blood glucose levels regularly.
- D. Avoid eating foods high in potassium.
Correct answer: C
Rationale: Monitoring blood glucose levels regularly is crucial for clients with type 2 diabetes who are taking metformin. This helps assess the effectiveness of the medication in managing blood sugar levels and allows for timely adjustments in the treatment plan if needed. By monitoring blood glucose levels, the client and healthcare team can work together to achieve optimal diabetes control and prevent complications associated with uncontrolled blood sugar levels.
4. What should the nurse include in patient teaching for a patient prescribed ceftriaxone for bacterial pneumonia?
- A. Take the medication as prescribed.
- B. Expect urine color changes.
- C. Complete the full course of the antibiotic.
- D. Avoid dairy products during treatment.
Correct answer: C
Rationale: When educating a patient prescribed ceftriaxone for bacterial pneumonia, it is crucial to emphasize completing the full course of the antibiotic. Completing the full course helps ensure the infection is completely eradicated and reduces the risk of antibiotic resistance. Incomplete courses of antibiotics can lead to treatment failure and the development of resistant bacterial strains. Therefore, it is essential for patients to adhere to the prescribed treatment regimen to achieve optimal outcomes.
5. What instruction should the nurse give regarding the administration of alendronate to a patient with osteoporosis?
- A. Take the medication with milk.
- B. Lie down for 30 minutes after taking the medication.
- C. Take the medication with a full glass of water.
- D. Take the medication before bedtime.
Correct answer: C
Rationale: The correct instruction for administering alendronate to a patient with osteoporosis is to take the medication with a full glass of water first thing in the morning. It is important for the patient to remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Taking alendronate with milk, lying down after intake, or taking it before bedtime can reduce the medication's effectiveness or increase the risk of side effects.
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