Test Bank for ATI RN-Adult Medical Surgical Nursing Detailed Answer Key ATI Complex Endocrine Practice Latest
ATI RN-Adult Medical Surgical Nursing Detailed Answer Key ATI Complex Endocrine Practice Latest-A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidecto...
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:08/13/2022 Page 1
, Detailed Answer Key
ATI Complex Endocrine Practice
Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset
of action of less than 30 min. This is the insulin that is most appropriate in emergency situations
of severe hyperglycemia or diabetic ketoacidosis.
3. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
A. Dehydration
Rationale: Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.
B. Polyphagia
Rationale: Polyphagia is a finding of diabetes mellitus, not insipidus.
C. Hyperglycemia
Rationale: Hyperglycemia is a finding of diabetes mellitus, not diabetes insipidus.
D. Bradycardia
Rationale: Tachycardia, not bradycardia, is a manifestation of diabetes insipidus.
4. A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify
which of the following findings as an indication that the medication is effective?
A. A decrease in blood sugar
Rationale: Blood sugar level is not affected in diabetes insipidus.
B. A decrease in blood pressure
Rationale: Diabetes insipidus causes the loss of large amounts of urine, which can lead to hypotension.
An increase (or at least no further decrease) in blood pressure would be the desired response to
vasopressin.
C. A decrease in urine output
Rationale: The major manifestations of diabetes insipidus are excessive urination and extreme thirst.
Vasopressin is used to control frequent urination, increased thirst, and loss of water associated
with diabetes insipidus. A decreased urine output is the desired response.
D. A decrease in specific gravity
Rationale: An increase in specific gravity (indicating a more concentrated urine) would be the desired
response of vasopressin.
5. A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic
acidosis. Which of the following results should the nurse expect to see?
Created on:08/13/2022 Page 2
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