ATI RN
ATI Med Surg Adult Care 2 Questions
Question 1 of 5
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Correct Answer: A
Rationale: A Romberg's test is used to assess balance and coordination, which are impaired in clients with ataxia.
Question 2 of 5
A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: Elevating side rails, placing the bed in the lowest position, providing suction, and keeping oxygen at the bedside are all appropriate interventions to ensure safety and manage potential complications during a seizure.
Question 3 of 5
A nurse is preparing to administer Tissue plasminogen activator (tPA). What is the likely reason the client will receive this treatment?
Correct Answer: D
Rationale: The client experienced an ischemic stroke is a reason to administer tPA, which is the standard treatment for this condition if given within 4.5 hours of symptom onset.
Question 4 of 5
A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?
Correct Answer: B
Rationale: Pushing the painful stimulus away is a normal response that indicates intact motor function and voluntary movement.
Question 5 of 5
A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?
Correct Answer: C
Rationale: difficulty speaking is the priority assessment finding because it indicates a worsening of the client's neurological status and a possible increase in intracranial pressure.