ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 of 5
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Correct Answer: D
Rationale: Lethargy indicates increased intracranial pressure, a serious complication of concussion. Nuchal rigidity, Battle’s sign, and polyuria are not typical signs of increased ICP.
Question 2 of 5
A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct this. Which of the following problems with the traction setup?
Correct Answer: A
Rationale: Weights resting against the bed reduce traction effectiveness and must be corrected to hang freely. Other options describe correct traction setup.
Question 3 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: Sudden sleepiness may indicate increased intracranial pressure, a life-threatening complication requiring immediate reporting. Headache, diplopia, and ataxia are concerning but less urgent.
Question 4 of 5
A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Elevating the head of the bed improves comfort and reduces complications like aspiration in halo traction. Supine positioning, pelvic girdles, or foot elevation are not required.
Question 5 of 5
A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Avoiding strenuous activities for a week prevents further injury and supports recovery. Heat can worsen swelling, frequent questioning may be unnecessary, and encouraging prolonged sleep could mask worsening symptoms.