ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?
Correct Answer: C
Rationale: Widened pulse pressure is the difference between systolic and diastolic blood pressure, which increases as a compensatory mechanism to maintain cerebral perfusion in the face of increased ICP.
Question 2 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.
Question 3 of 5
When providing education to a student nurse about ways to avoid increased intracranial pressure, which of the following will the nurse include in the instructions? (Select All that Apply.)
Correct Answer: A,B,C,D
Rationale: Consulting with dietary to manage fluid and sodium intake, keeping the head at 25 degrees or lower to promote venous drainage, dimming lights to reduce stimulation, and ordering a stool softener to prevent straining are all measures to avoid increased ICP.
Question 4 of 5
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?
Correct Answer: B
Rationale: Restlessness is an early sign of increased ICP, indicating decreased cerebral oxygenation and impaired cognition.
Question 5 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.