ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2°C (100.8°F). Which of the following neurologic disorders should the nurse suspect?
Correct Answer: D
Rationale: Sudden headache, seizure, and hypertension suggest a hemorrhagic stroke, likely from a ruptured vessel.
Question 2 of 5
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Correct Answer: C
Rationale: Oliguria is expected in hypovolemic shock due to decreased renal perfusion.
Question 3 of 5
A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
Correct Answer: C
Rationale: Paradoxical chest movement (inward on inspiration, outward on expiration) is characteristic of flail chest.
Question 4 of 5
A nurse in a critical care unit is caring for a client who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: D
Rationale: Muffled heart sounds are a classic sign of cardiac tamponade due to pericardial fluid accumulation.
Question 5 of 5
A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
Correct Answer: B,D,E
Rationale: Severe dyspnea and hypotension (listed twice) are key signs of ARF due to impaired gas exchange.