ATI-RN Adult Medical Surgical Nursing Detailed Answer Key ATI Complex Endocrine Practice-latest Update
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Course
Med Surg 2
Institution
West Coast University
ATI-RN Adult Medical Surgical Nursing Detailed Answer Key ATI Complex Endocrine Practice-latest Update.1. A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. F...
ati rn adult medical surgical nursing detailed answer key ati complex endocrine practice latest update
ati complex endocrine practice
1 a nurse is caring for a client who is 1 day postoperative follo
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ATI Endocrine practice
Med Surg 2 (West Coast University)
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Detailed Answer Key
ATI Complex Endocrine Practice
1. A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling
sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess
the client?
A. Chvostek's sign
RATIONALE: The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal
thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of
the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's
sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response
would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular
excitability due to hypocalcemia.
B. Babinski's sign
RATIONALE: Babinski's sign is a diagnostic test for brain damage or upper motor neuron damage. It is positive
if the toes flare up when the nurse strokes the plantar aspect of the foot.
C. Brudzinski's sign
RATIONALE: Brudzinski's sign is an indication of meningeal irritation, such as in clients who have meningitis. With
the client supine, the nurse should place one hand behind his head and places her other hand on his
chest. The nurse then raises the client's head with her hand behind his head, while the hand on his chest
restrains him and prevents him from rising. Flexion of the client's lower extremities constitutes a
positive sign.
D. Kernig's sign
RATIONALE: Kernig's sign is an indication of meningeal irritation, such as in clients who have meningitis. The nurse
performs the maneuver with the client supine with his hips and knees in flexion. The inability to extend
the client's knees fully without causing pain constitutes a positive test.
2. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the
emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The
nurse should anticipate using which of the following types of insulin to treat this client?
A. NPH insulin
RATIONALE: Isophane NPH insulin is intermediate-acting. It has an onset of action of 1 to 3 hr and is not
appropriate for emergency treatment of ketoacidosis.
B. Insulin glargine
RATIONALE: Insulin glargine is a long-acting insulin, with an onset of 2 to 4 hr. It is not appropriate for
emergency treatment of ketoacidosis.
C. Insulin detemir
RATIONALE: Insulin detemir is an intermediate-acting insulin. It has an onset of action of 1 hr and is not
appropriate for emergency treatment of ketoacidosis.
D. Regular insulin
RATIONALE:
Created on:08/13/2018 Page 1
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