ATI RN
ATI Med Surg Exam N300 Exam Day Questions
Question 1 of 5
The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)
Correct Answer: A,C,E
Rationale: Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.
Question 2 of 5
A patient diagnosed with a seizure disorder tells the nurse that they feel like they have 'butterflies' in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:
Correct Answer: C
Rationale: An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like 'butterflies,' which serve as a warning sign.
Question 3 of 5
The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?
Correct Answer: A
Rationale: Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.
Question 4 of 5
The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?
Correct Answer: D
Rationale: Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing.
Question 5 of 5
When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate a prescription for which of the following medications to manage increases in intracranial pressure (ICP)?
Correct Answer: C
Rationale: Hypertonic saline (3% Normal Saline) is used to reduce intracranial pressure by drawing fluid out of the brain tissue and into the bloodstream, which can help prevent cerebral edema.