ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: This is correct because clear fluid draining from the nose could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication of head trauma. Allowing the drainage to drip onto a sterile gauze pad can help confirm the presence of CSF by observing a halo sign.
Question 2 of 5
After performing a neurological assessment, the student nurse shares the following findings with the primary nurse: Visual fields full to confrontation with Intact extraocular movements. No nystagmus, midline protrusion of tongue, and negative Romberg test. Which of the following will the primary nurse tell the student nurse to document?
Correct Answer: B
Rationale: This choice is correct because the findings indicate that the visual fields, extraocular movements, cranial nerves IX and XII (glossopharyngeal and hypoglossal), and vestibular function are normal.
Question 3 of 5
An 84year old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?
Correct Answer: D
Rationale: Subacute subdural hematoma: This is correct because subacute subdural hematomas occur within 2 to 14 days of head trauma and cause gradual and fluctuating changes in mental status, which may be mistaken for dementia or delirium.
Question 4 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 5 of 5
Which of the following clients is most at risk for traumatic brain injury?
Correct Answer: C
Rationale: A 18year old highschool graduate who is enrolling in the Army: This is correct because military personnel are at high risk of traumatic brain injury due to exposure to blasts, projectiles, falls, and assaults.