ATI-AMS ATI Adult medical surgical Exam - Set 3 - Part 2

Correct Answer: Avoid bending over at the waist

Bending at the waist raises intraocular pressure, which can disrupt healing after cataract surgery. Avoiding this and similar straining activities protects the operative eye during the recovery period when intraocular pressure must remain controlled and stable. Option b is incorrect because tilting the head back to wash hair increases intraocular pressure and should be avoided after surgery. This position works against eye protection, so the client should keep the head from extending backward during hair washing throughout recovery. Option c is incorrect because resuming golf within two days involves rapid, jerky movements that strain the healing eye. Such activity is limited during early recovery, so returning to it this soon could endanger the surgical result and the operative eye. Option d is incorrect because lying on the operative side places pressure on the healing eye and is discouraged after the procedure. The client should avoid this position to keep direct pressure off the su

Correct Answer: Open-angle glaucoma

Primary open-angle glaucoma decreases aqueous outflow, gradually raising intraocular pressure and producing a slow, painless loss of peripheral vision. Diabetes is a recognized risk factor, which fits this client's gradual presentation closely and points toward this diagnosis. Option a is incorrect because a cataract clouds the lens and impairs both central and peripheral vision through opacity, often with an absent red reflex. The pattern of isolated peripheral loss described here points instead toward gradually rising intraocular pressure within the eye. Option b is incorrect because macular degeneration destroys central vision by damaging the macula, leaving peripheral sight relatively intact. Because this client is losing the outer visual field rather than the center, this particular diagnosis does not match the reported pattern here. Option c is incorrect because angle-closure glaucoma strikes suddenly with severe eye pain, nausea, halos, and a fixed pupil. The slow, painless

Correct Answer: A slow heart rate and trouble breathing

Timolol is a beta blocker that can be absorbed systemically, causing bradycardia, hypotension, and bronchoconstriction. The client should report a slow heart rate or trouble breathing, especially given the caution required in asthma or chronic lung disease. Option a is incorrect because increased appetite and weight gain are not effects of this beta blocker. Timolol's systemic concerns involve the heart and lungs, so directing the client to watch for appetite changes would miss its true adverse profile and dangers. Option b is incorrect because darkening of the iris is associated with prostaglandin analogs used for glaucoma, not with timolol. The client has confused a pigment change from a different drug class with the cardiopulmonary effects that the beta blocker actually causes here. Option d is incorrect because mild eye stinging can occur, but excessive tearing is not the priority systemic effect to report. The serious risks of timolol are the slow heart rate and bronchospasm

Correct Answer: Unilateral sensorineural hearing loss

Meniere's disease is marked by episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss that typically affects one ear. Unilateral sensorineural loss reflects the inner-ear involvement that defines this disorder and distinguishes it from middle-ear problems. Option a is incorrect because bulging red eardrums indicate a middle-ear problem such as otitis media, not an inner-ear disorder. Meniere's disease arises in the cochlea and semicircular canals, beyond the eardrum that this particular finding actually describes during examination of the ear. Option c is incorrect because purulent drainage in the canal suggests an external or middle-ear infection. Meniere's disease does not produce canal discharge, because its pathology lies within the fluid-filled inner ear rather than the outer pathway that this drainage would involve. Option d is incorrect because loss of the gag reflex points to cranial nerve involvement affecting swallowing, not to inner-ear disease

Correct Answer: I will avoid bending from the waist

After middle-ear surgery the client should restrict rapid movements and avoid bending from the waist for several weeks to protect the surgical site. Limiting these pressure-raising activities supports healing through the tympanic membrane surgical approach used. Option b is incorrect because hearing is decreased right after surgery because of fluid and packing within the ear. Expecting immediate normal hearing is incorrect, since the temporary loss resolves only as the swelling and the packing gradually clear away over time. Option c is incorrect because there is no external dressing to remove, because this surgery is performed through the tympanic membrane itself. A client planning to take off an outer dressing has misunderstood how the procedure was actually accessed and what was placed. Option d is incorrect because air travel is avoided for several weeks after middle-ear surgery, because pressure changes can disturb healing. Flying within a few days would expose the operative ear t

Correct Answer: Keep the client's neck stabilized

Any client with a head injury may have a concurrent cervical spine injury. Keeping the neck stabilized first prevents movement that could cause permanent spinal cord damage, which is the greatest risk until injury is ruled out by imaging. Option a is incorrect because controlling the forehead bleeding matters, yet scalp wounds bleed heavily without being immediately life-threatening. Protecting the spinal cord from a movement-induced injury outranks managing a laceration that simply is not the priority threat in this scenario. Option b is incorrect because intravenous access supports fluids and medications, but establishing a line involves handling that could shift an unstable spine. Securing the neck must precede interventions that risk moving a potentially injured cervical column in this unresponsive client. Option d is incorrect because vital signs guide ongoing care, though obtaining them does not address the danger of an unstable cervical spine. The priority is preventing cord dam

Correct Answer: Administer a prescribed stool softener

A stool softener prevents straining during bowel movements, which would trigger a Valsalva maneuver and raise intracranial pressure. Avoiding this strain helps keep the pressure controlled in a client who is already at risk after a head injury. Option b is incorrect because frequent suctioning raises intracranial pressure by stimulating coughing and gagging. Rather than helping, this action would worsen the very pressure the nurse is trying to limit, so it should be kept to a minimum in this client. Option c is incorrect because stacking two pillows hyperflexes the neck, which obstructs venous drainage from the head and increases intracranial pressure. The head should stay midline and neutral with the bed raised, not propped forward into flexion as this option describes. Option d is incorrect because encouraging large fluid intake risks overhydration, which can increase cerebral edema and intracranial pressure. Fluids are given carefully to maintain perfusion while avoiding the excess

Correct Answer: Decorticate posturing

Decorticate posturing, with adduction of the arms and flexion of the elbows and wrists, signals deteriorating motor function from increased intracranial pressure. This abnormal posture accompanies declining consciousness and pupillary changes as the pressure within the skull rises. Option a is incorrect because increased intracranial pressure produces bradycardia, not tachycardia, as part of Cushing's triad. A slowing heart rate, rather than a fast one, accompanies the rising pressure, so tachycardia actually points away from this developing complication in the client. Option b is incorrect because rising intracranial pressure causes hypertension with a widening pulse pressure rather than hypotension. The blood pressure climbs as a late compensatory response, so a low pressure does not signal this developing emergency the nurse is watching for here. Option c is incorrect because pupils that constrict and react briskly are a normal, reassuring finding. Rising pressure within the sk

Correct Answer: Loss of depth perception

A right-hemispheric stroke disrupts visual and spatial processing, causing loss of depth perception along with unilateral neglect and poor impulse control. These deficits reflect the right hemisphere's role in spatial perception and judgment rather than language. Option b is incorrect because expressive aphasia arises from left-hemispheric damage, where language is centered. A right-hemispheric stroke spares speech production, so difficulty expressing words points to the opposite side of the brain from this client's actual injury and location. Option c is incorrect because weakness appears on the side opposite the stroke, so a right-hemispheric event causes left-sided hemiplegia. Right-sided paralysis would instead indicate a left-hemispheric stroke, not the right-sided lesion that this particular client has sustained in the brain. Option d is incorrect because slow, cautious behavior with depression characterizes left-hemispheric strokes. A right-hemispheric stroke instead p

Correct Answer: Place food on the unaffected side

Placing food on the unaffected side of the mouth uses the stronger muscles for chewing and swallowing, which lowers the aspiration risk. This positioning, with the client upright and the chin tucked, supports safe feeding in dysphagia. Option a is incorrect because extending the neck backward opens the airway and increases the aspiration risk. The client should instead flex the head slightly forward in a chin-tuck position, which directs food toward the esophagus rather than into the trachea while swallowing. Option b is incorrect because thin liquids are difficult to control and easily aspirated by a client who has dysphagia. Thickened consistencies are used to slow the flow, giving the impaired swallow more time to close off and protect the airway during meals. Option d is incorrect because feeding should not be delegated to assistive personnel, because swallowing must be assessed and the aspiration risk is high. The nurse provides the initial feeding to monitor the client's abi

Correct Answer: Place the bedside table on the right

With left homonymous hemianopsia the client cannot see the left visual field, so placing the bedside table on the right keeps items within sight. This positioning lets the client locate and reach belongings using the preserved visual field. Option a is incorrect because the client should be taught to scan toward the left, the side of the lost vision, in order to compensate. Scanning toward the seen right side ignores the very field that actually needs deliberate and repeated visual searching. Option b is incorrect because the clock-position method fails, because the client sees only half of any surface and misses items on the left. Describing food by clock numbers wrongly assumes the full visual perception that this client no longer possesses after the stroke. Option c is incorrect because the wheelchair should be placed on the unaffected right side so the client sees it during transfers. Positioning it on the unseen left side would put it outside the client's visual awareness and

Correct Answer: Sit the client upright

These findings indicate autonomic dysreflexia, an emergency in injuries above the sixth thoracic level. Sitting the client upright first uses postural hypotension to lower the dangerously high blood pressure and reduce stroke risk before treating the trigger. Option b is incorrect because checking the catheter addresses the most common trigger, a distended bladder, but it follows raising the client up. The immediate threat is the soaring blood pressure, which sitting upright begins to lower right away before the cause is then corrected. Option c is incorrect because an antihypertensive may be needed for persistent hypertension, yet medication is not the first step. Positioning the client upright acts faster to drop the pressure, and the drug is reserved for use only if the dangerous surge continues afterward. Option d is incorrect because removing tight clothing can ease a contributing stimulus, but it does not match the urgency of the blood pressure crisis. Sitting the client up is th

Correct Answer: Respiratory status

A high cervical injury threatens the phrenic nerve and spontaneous ventilation, which makes respiratory status the priority. Following the airway, breathing, and circulation framework, monitoring breathing comes first because hypoxia can cause rapid brain injury and death. Option a is incorrect because bladder distention is an important concern in spinal cord injury and can even trigger autonomic dysreflexia, yet it is not immediately life-threatening. Breathing must be secured first, since ventilation failure kills far faster than urinary retention does in this client. Option b is incorrect because skin integrity matters, because the client cannot feel or relieve pressure, but breakdown develops gradually over time. The priority remains the airway and breathing, which can fail within minutes at this high cervical level of injury to the cord. Option c is incorrect because monitoring bowel sounds helps detect an ileus, a recognized complication, though it does not address the urgent ris

Correct Answer: A muscle relaxant for spasticity

During spinal shock the muscles are flaccid and reflexes are absent, so spasticity does not occur until shock resolves over days to weeks. A muscle relaxant is unnecessary now, which makes this order the one to clarify with the provider. Option a is incorrect because anticoagulants are appropriate, because immobility from the injury raises the risk of venous thromboembolism. Preventing clots is a valid early intervention in this client, so this prescription supports care rather than warranting clarification with the provider at this time. Option c is incorrect because a plasma expander treats the low blood pressure that accompanies spinal shock from the loss of sympathetic tone. Supporting blood pressure during this period is clearly indicated, so this order aligns well with the client's current physiologic needs. Option d is incorrect because an acid reducer guards against the stress ulcers that can develop after a severe injury. Reducing gastric acid is a reasonable precaution a

Correct Answer: Apply a condom catheter

An upper motor neuron injury, after spinal shock resolves, produces a spastic neurogenic bladder that empties reflexively. For a male client, a condom catheter manages the unpredictable reflex voiding while avoiding the infection risk of an invasive device. Option b is incorrect because intermittent catheterization suits a flaccid neurogenic bladder from a lower motor neuron injury, where reflex emptying is lost. A spastic bladder releases on its own, so a scheduled catheterization program does not fit this client's reflexive bladder pattern at all. Option c is incorrect because the Crede's method, applying manual pressure over the bladder, is used for a flaccid bladder that cannot empty reflexively. With a spastic bladder that voids by reflex, this external compression technique is simply not the appropriate intervention to include here. Option d is incorrect because an indwelling catheter is invasive and avoided when a less intrusive option will work. Because a condom cathe

Correct Answer: This checks my hip bone density

A dual-energy x-ray absorptiometry scan estimates bone mass density at the hip or spine to evaluate osteoporosis. The client correctly identifies its purpose, which guides the diagnosis and the baseline monitoring of bone loss over time. Option a is incorrect because this scan uses two radiation beams and requires no contrast solution. A client expecting to drink contrast has confused it with a different imaging study, since the bone-density test needs no such preparation or oral solution beforehand at all. Option b is incorrect because the scan detects osteoporosis, not osteoarthritis, which is a joint cartilage disorder diagnosed by other means. Measuring bone density does not evaluate the cartilage deterioration that defines osteoarthritis, so this expectation about the test is simply incorrect here. Option c is incorrect because no tube is involved in a bone-density scan, since that feature belongs to magnetic resonance imaging instead. The client lies on a table while the beams me

Correct Answer: Anticoagulants will be withheld beforehand

Electromyography involves inserting needles into the muscle, so anticoagulants are contraindicated, because they raise the risk of intramuscular bleeding. Withholding these medications beforehand protects the client from bleeding into the muscle during the procedure and afterward. Option a is incorrect because taking aspirin works against the goal, because aspirin increases the bleeding risk during needle insertion. Anticoagulants and similar agents are held rather than added, so this instruction would actually endanger the client undergoing this needle-based muscle test. Option b is incorrect because electromyography is not painless, since the client should expect discomfort as the needles enter the muscle. Telling the client to anticipate no sensation misrepresents the procedure and could leave them unprepared for what they will actually experience during it. Option d is incorrect because creams and lotions are avoided before the test, because they interfere with electrode contact an

Correct Answer: A respiratory infection two weeks ago

A recent infection is a contraindication to arthroplasty, because micro-organisms can migrate to the new joint and cause prosthesis failure. A respiratory infection two weeks ago raises this risk and must be reported to the provider before surgery proceeds. Option a is incorrect because a previous joint replacement does not prevent another arthroplasty and is not a contraindication on its own. Without an accompanying complication, having had a prior prosthesis poses no barrier to performing this surgery safely in the client at this time. Option c is incorrect because a history of cancer alone does not contraindicate joint replacement in the absence of uncontrolled comorbidities. This past diagnosis does not introduce the infection-related prosthesis risk that would actually halt the planned procedure for the client before surgery. Option d is incorrect because advanced age is not itself a contraindication to arthroplasty. Being older does not threaten the implant the way a recent activ

Correct Answer: Place a pillow under the lower calf

Placing a pillow under the lower calf keeps the knee in slight extension and helps prevent flexion contractures. This positioning, combined with keeping the heels off the bed, protects range of motion after a knee replacement procedure. Option a is incorrect because a pillow behind the knee holds the joint in flexion and promotes a flexion contracture. The goal is to keep the knee extended, so the support belongs under the calf rather than directly behind the knee itself. Option b is incorrect because ice, not heat, is applied after knee arthroplasty to reduce swelling and pain. A heating pad would increase circulation and edema at the operative site, which works against the cooling that the healing joint actually requires during recovery. Option d is incorrect because the heels should be kept off the bed to prevent pressure injury and to support proper alignment. Letting the heels rest on the mattress leaves them vulnerable to skin breakdown during recovery, so this position is avoide

Correct Answer: Administer a prescribed antiepileptic

Sharp, stabbing phantom limb pain responds to antiepileptic medications such as gabapentin or pregabalin. These adjuvant drugs target the abnormal nerve signaling that produces this pain, providing appropriate relief for the burning, stabbing sensation the client describes. Option a is incorrect because the initial pressure dressing should not be removed by the nurse, since it supports the residual limb and controls swelling. Taking it off does nothing for phantom pain and could disrupt the healing surgical site beneath it on the limb. Option c is incorrect because heat, rather than cold, is used as a nonpharmacological measure for phantom limb pain. Applying a cold pack does not match the recommended approach and would not address the nerve-based discomfort that this client is currently experiencing in the limb. Option d is incorrect because phantom limb pain is real and results from severed nerve pathways. Telling the client otherwise dismisses a genuine experience, so the nurse shou