ATI Custom MS Nurse | Nurselytic

Questions 47

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Extract:

Client restless following a traumatic brain injury with increased intracranial pressure


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: An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure.

Extract:

Client difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure


Question 2 of 5

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Correct Answer: B

Rationale: The nurse should use the term 'postictal phase' when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.

Extract:

Client unconscious following a stroke


Question 3 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: The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.

Extract:

Client with a fractured femur


Question 4 of 5

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

Correct Answer: A

Rationale: The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur.

Extract:

Client with a traumatic head injury


Question 5 of 5

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

Correct Answer: A

Rationale: The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.

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