ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?
Correct Answer: B
Rationale: Pushing the painful stimulus away is a normal response that indicates intact motor function and voluntary movement.
Question 2 of 5
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Correct Answer: A
Rationale: A Romberg's test is used to assess balance and coordination, which are impaired in clients with ataxia.
Question 3 of 5
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
Correct Answer: A
Rationale: A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would need total nursing care and close monitoring.
Question 4 of 5
A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.
Correct Answer: B,C,D
Rationale: Increased ICP leads to ischemia due to reduced cerebral perfusion, hypotension as a late compensatory mechanism, and hyperventilation as a respiratory response to acidosis.
Question 5 of 5
According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?
Correct Answer: A
Rationale: Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration. Identifying and treating the cause can help resolve the delirium and prevent further complications.