ATI RN
ATI n269 Med Surg Exam 1 Questions
Question 1 of 5
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Correct Answer: B
Rationale: A decreased level of consciousness is a hallmark sign of increased ICP, as pressure on the brainstem impairs consciousness. Hypotension is not typical, as ICP often causes hypertension. Tachypnea is less specific, and bilateral weakness may occur but is not as directly indicative.
Question 2 of 5
Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis?
Correct Answer: D
Rationale: A decrease in glucose levels is characteristic of bacterial meningitis due to bacterial consumption and inflammation. Lymphocytes increase in viral meningitis, while neutrophils and protein levels are elevated in bacterial meningitis.
Question 3 of 5
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
Correct Answer: A
Rationale: Left-sided strokes impair language and speech functions, making effective communication a priority goal. Impulsive behavior and depth perception issues are associated with right-sided strokes, and left-side motor deficits result from right hemisphere damage.
Question 4 of 5
When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include?
Correct Answer: B
Rationale: Blood pressure, brain tissue, and cerebrospinal fluid are the primary components of ICP balance. Changes in these affect skull pressure. Glucose levels and BMI are unrelated, and ventricles are involved in CSF production but not a primary component.
Question 5 of 5
A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client?
Correct Answer: A,B,E
Rationale: Dim lighting increases fall risk, a hot water heater at 54°C risks burns, and area rugs pose tripping hazards, all dangerous for stroke patients with mobility issues. Grab bars enhance safety, and clear bag storage is not hazardous if organized.