ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 of 5
A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?
Correct Answer: C
Rationale: Reducing stimuli (e.g., noise, light, visitors) calms the client and prevents further increases in intracranial pressure. Opioids, restraints, or complete darkness may be inappropriate or less effective.
Question 2 of 5
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Correct Answer: C
Rationale: Suctioning saliva prevents aspiration and maintains a patent airway, which is critical for survival in an unconscious client. Other interventions are important but secondary to airway management.
Question 3 of 5
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?
Correct Answer: C
Rationale: A wedge pillow between the legs maintains proper alignment and prevents leg crossing or adduction, reducing the risk of hip dislocation. Trochanter rolls prevent external rotation, sandbags prevent foot drop, and footboards prevent plantar flexion contractures, none of which directly prevent dislocation.
Question 4 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye-opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: D
Rationale: A GCS score of 3 for eye-opening indicates the client opens their eyes in response to voice, making option D correct. The client is not unconscious, can make vocal sounds (verbal score of 5), and may not follow commands (motor score of 5 indicates localizing pain).
Question 5 of 5
A nurse is collecting data from a client who has rheumatoid arthritis. Which of the following is an expected finding for this client?
Correct Answer: B
Rationale: Boutonniere deformity is a characteristic hand deformity in rheumatoid arthritis, involving a bent middle finger joint and hyperextended fingertip.
Tophi are associated with gout, osteoma with benign bone tumors, and Heberden's nodules with osteoarthritis.