ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 of 5
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?
Correct Answer: C
Rationale: Checking the temperature assesses for fever, a key symptom of meningitis, which may present with headache and stiff neck. Other actions follow based on findings.
Question 2 of 5
A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?
Correct Answer: C
Rationale: Reducing stimuli (e.g., noise, light, visitors) calms the client and prevents further increases in intracranial pressure. Opioids, restraints, or complete darkness may be inappropriate or less effective.
Question 3 of 5
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Correct Answer: D
Rationale: Lethargy indicates increased intracranial pressure, a serious complication of concussion. Nuchal rigidity, Battle’s sign, and polyuria are not typical signs of increased ICP.
Question 4 of 5
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
Correct Answer: A,D,E
Rationale: Applying a compression bandage reduces swelling and supports the injured area. Elevating the foot promotes venous return to decrease swelling. Checking toes for color, temperature, and sensation assesses for nerve or vascular damage. Heat can increase swelling and inflammation, and encouraging range of motion may worsen the injury.
Question 5 of 5
A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Elevating the ankle to heart level reduces swelling per the RICE method. Tight compression, weight-bearing, and heat in the first 24 hours can worsen the injury.