ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A client admitted after a motor vehicle accident arrives with a Glasgow coma score (GCS) of 14 with a mild headache. 4 hours later, the client's GCS has decreased to 10 , and now has a dilated pupil on the left side. Which of the following acute traumatic brain injuries does the nurse suspect the client has suffered?
Correct Answer: D
Rationale: Epidural hematoma is suspected due to the lucid interval and dilated pupil on the opposite side, indicating third cranial nerve compression. Lacerations, subdural hematomas, and intracerebral hemorrhages do not typically present this way.
Question 2 of 5
A nurse is performing a focused assessment for a client's vision. What visual assessment is the nurse making when she extends her hand for the client to shake?
Correct Answer: B
Rationale: Depth perception is the ability to judge the distance and position of objects in three-dimensional space. Depth perception is assessed by asking the client to touch the tip of a pen or pencil held by the nurse, or by using a stereopsis test. Peripheral vision is the ability to see objects and movements outside the direct line of vision. Peripheral vision is assessed by asking the client to shake the hand of the nurse, who stands at an angle to the client's side, or by using a confrontation test. Color deficit is the inability to distinguish certain colors or shades of colors. Color deficit is assessed by asking the client to identify numbers or shapes on a color plate test, such as the Ishihara test. Double vision is the perception of two images of a single object. Double vision is assessed by asking the client to cover one eye and look at an object, then switch eyes and compare the images, or by using a cover-uncover test.
Question 3 of 5
A nurse caring for a client with hepatitis is providing education to the client about portal hypertension. Which of the following will the nurse include in the teaching?
Correct Answer: A
Rationale: Increased pressure from portal hypertension causes abdominal swelling (ascites). It is not caused by heart overworking, and it worsens, not resolves, with cirrhosis.
Question 4 of 5
A nurse collects health history from a 65 year old client. Which of the following risk factors in the client's history puts the client at the highest risk for embolic stroke?
Correct Answer: A
Rationale: Atrial fibrillation increases the risk of embolic stroke by causing blood pooling in the heart, leading to clot formation that can travel to the brain and block an artery.
Question 5 of 5
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: A throbbing headache is a common symptom of meningitis due to increased intracranial pressure and meningeal irritation. Inability to read suggests a stroke or brain tumor, bruising around the eyes suggests a skull fracture, and a heart rate of 50 suggests bradycardia, none of which are typical for meningitis.