Questions 54

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ATI Advanced Med Surg Cohort 4 Exam Questions

Extract:


Question 1 of 5

A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?

Correct Answer: C

Rationale: Assessing the client's symptoms is crucial to monitor for stroke progression and guide interventions, especially with changing vital signs.

Question 2 of 5

A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Correct Answer: B

Rationale: Respiratory status is the priority post-surgery due to risks of compromised airway or ventilation from altered consciousness or complications.

Question 3 of 5

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Correct Answer: B

Rationale: Phenytoin is associated with gingival hyperplasia, making inspection of the oral mucosa critical for detecting this adverse effect.

Question 4 of 5

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

Correct Answer: B

Rationale: Urinary symptoms like urgency, frequency, or incontinence are common in MS due to neurogenic bladder dysfunction, making this inquiry essential for assessing neurological involvement.

Question 5 of 5

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following medication would the nurse anticipate to administer?

Correct Answer: B

Rationale: IV lorazepam is the first-line treatment for acute seizure termination, acting quickly to suppress seizure activity.

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