ATI Npro 2100 Med Surg Exam

Question 1 of 5

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

A. Establish a plan of care with the client that sets attainable goals.B. Inform the client that privileges are related to participation in therapy.C. Limit visiting hours until the client begins to participate in therapy.D. Allow the client to control the timing and frequency of the therapy.

Correct Answer: A

Rationale: This option focuses on involving the client in their own care and goal-setting. By establishing attainable goals together, the nurse can help the client regain a sense of control and motivation, which may encourage participation in therapy.

Question 2 of 5

A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia?(Select All that Apply.)

A. Sexual intercourseB. Loose clothingC. NauseaD. Surgery below level of injuryE. Urinary tract infections

Correct Answer: A,D,E

Rationale: Sexual activity can trigger autonomic dysreflexia due to increased stimulation of the pelvic nerves. Surgery below the level of injury can be perceived as a noxious stimulus, leading to a reflexive autonomic response. Urinary tract infections cause irritation and stimulation of the bladder, triggering autonomic dysreflexia.

Question 3 of 5

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

A. Independent control of bowel and bladder functionB. Use of a wheelchair with a chin or mouth stickC. Ability to achieve independent transfer from bed to wheelchairD. Ability to self-feed with the use of adaptive equipment

Correct Answer: B

Rationale: At the C5 level, clients have significant limitations in motor function below the injury. Using a wheelchair with a chin or mouth stick is a realistic goal, enabling mobility with adaptive devices.

Question 4 of 5

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?

A. Complete a neurological check on the client.B. Place the client in a rigid cervical collar.C. Open the client's airway using the jaw-thrust maneuver.D. Evaluate the client for other injuries.

Correct Answer: C

Rationale: The jaw-thrust maneuver opens the airway without flexing the neck, crucial in suspected cervical spine injuries, prioritizing airway patency in a non-breathing client.

Question 5 of 5

A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

A. Provide the client with a fixed showerhead.B. Give the client a long-handled sponge.C. Fill the client's bathtub with water at 48° C (118.4° F).D. Offer the client bar soap.

Correct Answer: B

Rationale: A long-handled sponge promotes independence and safety by allowing the client to reach different body parts without significant movement.

ATI Npro 2100 Med Surg Exam | Nurselytic

Nurselytic

ATI RN

ATI RN