ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following is not an appropriate action for the nurse to take?
Correct Answer: B
Rationale: Placing the client's head on the nurse's lap may obstruct his airway and increase the risk of aspiration.
Question 2 of 5
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
Correct Answer: A
Rationale: A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would need total nursing care and close monitoring.
Question 3 of 5
A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?
Correct Answer: D
Rationale: An epidural hematoma is caused by bleeding between the dura mater and the skull, usually from a ruptured artery. The bleeding can cause increased intracranial pressure, which can compress the brain and lead to a loss of consciousness.
Question 4 of 5
A nurse is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Turning the client's head to the side is the first action that the nurse should take to prevent aspiration of saliva or vomitus and maintain a patent airway during a seizure.
Question 5 of 5
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
Correct Answer: C
Rationale: Establishing the ability to communicate effectively is an appropriate goal for a client with a left hemispheric CVA, which affects language functions.