ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.
Correct Answer: D
Rationale: Prepare the client for mechanical ventilation. This is the best first action because the client has Saclay has a very low Glasgow Coma score and may lose the ability to breathe spontaneously or maintain adequate oxygenation.
Question 2 of 5
A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.
Correct Answer: B,C,D
Rationale: Increased ICP leads to ischemia due to reduced cerebral perfusion, hypotension as a late compensatory mechanism, and hyperventilation as a respiratory response to acidosis.
Question 3 of 5
A nurse is monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply
Correct Answer: B,C,D,E
Rationale: Stage 3 ICP is characterized by hypotension, widened pulse pressure, bradycardia with a bounding pulse, and uneven breathing due to severe brain compression.
Question 4 of 5
A student nurse is asked by the preceptor to identify which of the assigned clients is at the highest risk for stroke. Which of the clients below, when selected by the student nurse, indicate an understanding of the highest risk factor for stroke?
Correct Answer: D
Rationale: A client treated for atrial fibrillation with clopidogrel (Plavor) Correct. Atrial fibrillation is a condition that causes irregular and rapid heartbeats, which can lead to blood clots forming in the heart and traveling to the brain, causing a stroke.
Question 5 of 5
When considering the client with a neurocognitive deficit, the nurse understands that which of the following are excitatory neurotransmitters?
Correct Answer: B,C
Rationale: Norepinephrine and Dopamine are excitatory neurotransmitters that increase arousal, alertness, attention, motivation, reward, and movement.