ATI Detailed Answer Key Medical Surgical

ATI Detailed Answer Key Medical Surgical Related

Review ATI Detailed Answer Key Medical Surgical related questions and content

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: B

Rationale: The correct answer is B: Weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on neuromuscular junctions. Monitoring for weakness is essential to assess disease progression and response to treatment. Confusion (A) is not a typical manifestation of myasthenia gravis. Increased intracranial pressure (C) is more commonly associated with conditions like head trauma or brain tumors. Increased urinary output (D) is not directly related to myasthenia gravis and is more indicative of conditions affecting the kidneys or fluid balance.

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A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant?

  • A. Administer IV fluids as prescribed by the physician.
  • B. Provide straws and offer fluids between meals.
  • C. Develop plan for added fluid intake over 24 hours.
  • D. Teach family members to assist client with fluid intake.
Correct Answer: B

Rationale: The nursing assistant can effectively encourage oral fluid intake by offering fluids between meals, which is within their scope of practice. Administering IV fluids, developing plans, and teaching family members are more advanced tasks that require higher-level nursing skills.

What does the nurse give priority to assessing immediately following Mr. Singer’s total laryngectomy?

  • A. Elimination patterns
  • B. Level of pain
  • C. Gag reflex
  • D. Respiratory status
Correct Answer: D

Rationale: Respiratory status is critical due to the altered airway anatomy.

The medical-surgical nurse performs a dressing change on a patient with a history of non-insulin-dependent diabetes. The patient questions why the wound is not healing. Recognizing a teaching opportunity, what response does the nurse offer the patient?

  • A. Are you eating enough carbohydrates in your diet?
  • B. Have you limited your exercise because of the wound?
  • C. How much sleep are you getting at night?
  • D. How often do you check your blood sugar levels at home?
Correct Answer: D

Rationale: Blood sugar control significantly impacts wound healing in diabetic patients.

How can a nurse foster effective coping skills?

  • A. Deep breathing exercises
  • B. Avoid social interactions
  • C. Ignore stressors
  • D. Increase workload
Correct Answer: B

Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.

Which of the following imbalances should the nurse check for in a pregnant client with hypertension and cardiac dysrhythmias?

  • A. Metabolic acidosis
  • B. Hypomagnesemia
  • C. Hypernatremia
  • D. Hypercalcemia
Correct Answer: B

Rationale: Hypomagnesemia is commonly associated with pregnancy-induced hypertension and can contribute to cardiac dysrhythmias. Magnesium plays a critical role in neuromuscular function and electrolyte balance.

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