ATI Medical Surgical Proctored Exam

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A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?

  • A. The client is experiencing an aura.
  • B. The client's antiseizure medication level is within the therapeutic range.
  • C. The client has been seizure-free for 2 years.
  • D. The client's seizure activity lasts longer than 5 minutes.
Correct Answer: D

Rationale: The correct answer is D because prolonged seizures lasting longer than 5 minutes can lead to status epilepticus, a medical emergency that can cause brain damage or even death. Immediate intervention is necessary to stop the seizure activity. Auras (A) are warning signs of an impending seizure and do not require immediate intervention. Antiseizure medication within therapeutic range (B) indicates proper management. Being seizure-free for 2 years (C) is a positive outcome but does not require immediate intervention unless a seizure occurs.

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What is the side effect caused by tyramine in foods when taking an MAOI inhibitor?

  • A. Cardiac dysrrhythmias
  • B. Thyroid storm
  • C. Hypertensive crisis
  • D. Rhabdomyolysis
Correct Answer: C

Rationale: Tyramine interacts with MAOIs to cause a dangerous rise in blood pressure, known as hypertensive crisis.

What nursing action is most important initially for Ms. Jenkins with pneumococcal pneumonia?

  • A. Administer humidified oxygen, as ordered
  • B. Obtain an order for aspirin
  • C. Auscultate the posterior basal segments for rales and rhonchi
  • D. Explain the diagnosis to the patient
Correct Answer: A

Rationale: Oxygen therapy addresses hypoxemia, a primary concern in pneumonia.

What is the term used for assessment data that the patient tells you about?

  • A. Focused
  • B. Objective
  • C. Subjective
  • D. Comprehensive
Correct Answer: C

Rationale: The correct answer is 'Subjective.' Subjective data includes patient-reported symptoms, feelings, and experiences.

How does the pain of a myocardial infarction (MI) differ from stable angina?

  • A. Accompanied by shortness of breath
  • B. Feelings of fear or anxiety
  • C. Lasts less than 15 minutes
  • D. No relief from taking nitroglycerin
Correct Answer: C

Rationale: The correct answer is C because the pain of a myocardial infarction (MI) typically lasts longer than 15 minutes, unlike stable angina which lasts for a shorter duration. MI pain is usually described as intense, crushing, and prolonged, whereas stable angina pain is often triggered by exertion and relieved by rest or medication like nitroglycerin. Choices A, B, and D are incorrect because shortness of breath, feelings of fear or anxiety, and lack of relief from nitroglycerin are not definitive differentiating factors between MI and stable angina.

For a patient on the chemotherapeutic drug vincristine (Oncovin), which of the following side effects should be reported to the physician?

  • A. Fatigue.
  • B. Nausea and vomiting.
  • C. Paresthesia.
  • D. Anorexia.
Correct Answer: C

Rationale: Paresthesia is a serious neurotoxic side effect of vincristine and requires immediate medical attention.

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