ATI LPN
Quizlet Adult Medical Surgical Head Injury Monitoring Neurological Status Questions
Question 1 of 5
The nurse is caring for an older male client with impaired skin integrity to sheering forces and pressure that is manifested as a draining stage 3 sacral ulcer. Which intervention is most important for the nurse to implement?
Correct Answer: B
Rationale: Protein aids wound healing, critical for stage 3 ulcers. A/C/D are supportive but secondary to nutrition. [Level: Analysis]
Question 2 of 5
A client with acute renal injury (AKI) weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse first administer?
Correct Answer: C
Rationale: Hyperkalemia (6.7, normal 3.5-5) risks cardiac arrest; sodium polystyrene sulfonate removes potassium fastest. Others address phosphate or anemia. [Level: Analysis]
Question 3 of 5
When the nurse begins discharge instructions for a client and her spouse, the client who had an above the knee amputation for complications associated with diabetes, tells the nurse that she is not ready to go home and wants to stay home in the hospital another day, which intervention is important for the nurse to implement?
Correct Answer: C
Rationale: Exploring fears identifies barriers to discharge readiness, guiding support. Others assume or bypass the root issue. [Level: Application]
Question 4 of 5
What concern should the nurse anticipate for a patient who had a right hemisphere stroke?
Correct Answer: C
Rationale: Right-brain strokes cause left-sided deficits and behavioral changes (denial, impulsivity). B is left-brain, A/D are less specific. [Level: Comprehension]
Question 5 of 5
Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?
Correct Answer: B
Rationale: Hypotension (90/50) signals shock or rebleed in SAH, requiring urgent intervention. Others are expected findings. [Level: Analysis]