ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis. Assessment findings include nuchal rigidity and a petechial rash. After Implementing droplet precautions, which of the following actions should the nurse initiate next?
Correct Answer: B
Rationale: Assessing cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.
Question 2 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 3 of 5
A client newly diagnosed with multiple sclerosis is receiving education about newly prescribed medications from the nurse. Which of the following will be included in the client teaching?
Correct Answer: D
Rationale: This is correct because immunomodulators are used to prevent relapses and slow down the progression of multiple sclerosis.
Question 4 of 5
A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.
Correct Answer: D
Rationale: Prepare the client for mechanical ventilation. This is the best first action because the client has Saclay has a very low Glasgow Coma score and may lose the ability to breathe spontaneously or maintain adequate oxygenation.
Question 5 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.