ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Question 1 of 5
The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?
Correct Answer: A
Rationale: Cushing's triad (hypertension, bradycardia, irregular respirations) is characteristic of increased intracranial pressure, reflecting brainstem compression.
Question 2 of 5
A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?
Correct Answer: B
Rationale: Phenytoin is associated with gingival hyperplasia, making inspection of the oral mucosa critical for detecting this adverse effect.
Question 3 of 5
A nurse is caring for a client who reports a throbbing headache and hypotension after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?
Correct Answer: C
Rationale: A blood patch seals the puncture site to restore cerebrospinal fluid pressure, directly addressing the cause of post-lumbar puncture headache.
Extract:
Nurses' Notes
Client admitted to the emergency department with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, and general muscle aches. The client reports diarrhea, abdominal pain, and a sore throat. Pupils are 3 mm, equal and reactive to light. Intermittent nystagmus noted. Client reports sensitivity to light.
Client is lethargic, but arouses easily and is oriented to person, place, and time. Hand grasps are strong and equal bilaterally.
Bilateral breath sounds are clear and present throughout. Apical pulse is regular.
Skin is warm and dry. Pinpoint, red, macular rash noted on upper chest. Abdomen is distended, bowel sounds are present in 4 quadrants.
Vital Signs
Temperature 38.9° C (102° F)
Blood pressure 168/80 mm Hg
Heart rate 118/min
Respiratory rate 24/min
Oxygen saturation 95% on room air
Question 4 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: B (Meningitis), A (Seizure precautions, Dim lights), C (Neurologic status, Temperature)
Rationale: Symptoms like headache, photophobia, and rash suggest meningitis, requiring seizure precautions and light reduction, with monitoring of neurologic status and temperature.
Extract:
Question 5 of 5
A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?
Correct Answer: C
Rationale: Positioning the patient laterally facilitates lumbar puncture and minimizes complications like post-dural puncture headache.