ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve.
Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve.
Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
Question 2 of 5
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Decrease protein intake. Nephrotic syndrome causes protein loss through urine, leading to hypoalbuminemia and edema. Decreasing protein intake can help reduce proteinuria and decrease the workload on the kidneys. Increasing phosphorus intake (
A) can worsen kidney function. Decreasing carbohydrate intake (
B) is not directly related to managing nephrotic syndrome. Increasing potassium intake (
D) is not recommended as it can lead to hyperkalemia in individuals with kidney issues.
Question 3 of 5
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
Correct Answer: A
Rationale: The correct answer is A because a capillary refill of 6 seconds in the left toe indicates poor circulation, which could lead to ischemia or necrosis in the extremity. Immediate intervention is necessary to prevent further complications.
Choice B is not as urgent as it involves monitoring and managing drainage, which can be addressed after the circulation concern is addressed.
Choice C, an elevated temperature, may indicate infection but is not as immediately life-threatening as poor circulation.
Choice D, pain at the operative site, is important but does not require immediate intervention as it can be managed with pain medication.
Question 4 of 5
A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Turn the client on their side. This is the first action the nurse should take during a seizure to prevent aspiration and maintain an open airway. Turning the client on their side helps to prevent choking and allows any fluids to drain out of the mouth. Obtaining vital signs (
A) and performing a neurologic check (
B) can be done after ensuring the client's safety. Notifying the rapid response team (
D) is important in some situations, but the immediate priority is to protect the client from harm during the seizure.
Question 5 of 5
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Instruct visitors to remain 3 feet from the client. This is because brachytherapy involves the internal placement of radioactive sources close to the tumor. By instructing visitors to remain 3 feet away, the nurse helps minimize their exposure to radiation.
A: Discarding the radioactive device in the client's trash can is incorrect as it can pose a radiation hazard to others.
B: Limiting time for visitors to 2 hours per day does not directly address radiation exposure concerns.
D: Keeping soiled bed linens in the client's room does not address radiation safety for visitors.
In summary, option C is the best choice as it directly addresses radiation safety for visitors during brachytherapy treatment.