ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 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 2 of 5
A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?
Correct Answer: C
Rationale: difficulty speaking is the priority assessment finding because it indicates a worsening of the client's neurological status and a possible increase in intracranial pressure.
Question 3 of 5
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased Intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?
Correct Answer: A
Rationale: A decrease in the Glasgow Coma Score indicates a deterioration in the level of consciousness, which is a sign of increased ICP.
Question 4 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 5 of 5
A client with multiple sclerosis has been prescribed interferon B. Which of the following statements indicates the client understands the teaching about this medication.
Correct Answer: B
Rationale: Interferon B can cause depression and suicidal ideation, so the client should monitor their mood and seek help if needed.