ATI Med Surg Adult Care 2 | Nurselytic

Questions 63

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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

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

Similar Questions

The nurse takes report on a client who was admitted with a severe headache, nausea, vomiting, photophobia, and a stiff neck. Which of the following is the priority intervention for the nurse to perform?
A physician tells the family of a client involved in a motorvehicle accident that the client sustained a coupcontrecoup injury. Which of the following statements by the nurse indicates an understanding of this type of traumatic brain injury?
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?
A nurse is preparing to administer intravenous mannitol, an osmotic diuretic, to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
A nurse suspects that a client has increasing intracranial pressure. Which of the following diagnostics does the nurse anticipate will be ordered?

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