ATI RN
ATI Custom MS Nurse Questions
Extract:
Client with a new concussion following a motor-vehicle crash
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: The nurse should monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal fluid.
Extract:
Client with multiple sclerosis learning four-point alternate gait with crutches
Question 2 of 5
A nurse is reinforcing teaching with a client who has multiple sclerosis and is learning how to use the four-point alternate gait with crutches. Identify the order of the steps the nurse should give to the client.
Correct Answer: A,B,C,D
Rationale: The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait pattern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.
Extract:
Client with an ankle sprain
Question 3 of 5
A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: The nurse should instruct the client to elevate the affected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood flow to the injured area.
Extract:
Client with a leg cast for a fractured wrist
Question 4 of 5
A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?
Correct Answer: A
Rationale: When a cast is too tight, it can compromise blood circulation to the extremity. This results in decreased blood flow and reduced oxygenation, causing the toes to feel cool to the touch.
Extract:
Client with a cast on right leg
Question 5 of 5
While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?
Correct Answer: B
Rationale: The nurse should identify infection as a complication to the client's condition. A warm area on the cast could indicate the presence of an underlying infection. The warmth could be due to an increase in blood flow to the area as the body tries to fight off the infection.