ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 45 Questions
Question 1 of 5
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
Correct Answer: D
Rationale: A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow/ Com Scale score of 12, a PaCOO of 36, and cerebral perfusion pressure of 72 mm Hg all desired outcomes.
Question 2 of 5
A client is the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
Correct Answer: D
Rationale: This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead is hesitation. Informed consent is needed for an LP. but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure/relation (or other preprocedure/mediations) should not be given as the LP will most likely be canceled.
Question 3 of 5
After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care.
Correct Answer: A
Rationale: Ataxia is a gait disturbance. For the clients safety, or she she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.
Question 4 of 5
A nurse cares for older clients who have traumatic brain injury. What should be nurse understand about this population? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and more because of decreased protective mechanisms. they are more susceptible to both older and systemic injuries. A moderate brain injuries are more susceptible to older and more susceptible to older and more related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.
Question 5 of 5
A nurse a caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first.
Correct Answer: A
Rationale: A client decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement on the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the decline the Glasgow Coma Scale score.