ATI RN
ATI Nsg 234 Med Surg Exam Neurologyendocrine And Sensory Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?
Correct Answer: C
Rationale: A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
Question 2 of 5
A nurse is performing a tonometry test on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23 mm Hg. What should the nurse's initial action be?
Correct Answer: D
Rationale: An IOP of 23 mm Hg is above the normal range (10-21 mm Hg) and indicates potential glaucoma.
Therefore, contacting the primary health care provider for further evaluation and treatment is the most appropriate initial action.
Question 3 of 5
A nurse is caring for a client that has been diagnosed with external otitis. Which of the following clinical symptoms should the nurse be monitoring?
Correct Answer: A,B,C,D,E
Rationale: Edema, purulent drainage, burning, pain when moving the auricle, and tenderness are all clinical symptoms of external otitis, indicating inflammation and infection in the ear canal.
Question 4 of 5
The nurse is caring for a client who sustained a head injury in a motor vehicle accident and is diagnosed with a subdural hematoma and increased intracranial pressure. Which nursing intervention is appropriate for this client?
Correct Answer: D
Rationale: Implementing seizure precautions is critical as head injuries can lead to seizures, and ensuring the client's safety is a priority.
Extract:
Nurses' Notes
Client appears lethargic and reports fatigue, a decrease in appetite, and a 20 lb weight gain over a 6-month period. Client reports hair loss and numbness and tingling in fingers.
Neck midline no visible abnormalities
Skin is pale, cool, and dry.
Client reports constipation. Abdomen is distended. Bowel sounds are hypoactive. Complains of inability to tolerate cold.
Vital Signs
Temperature 35.9° C (96.6° F)
Blood pressure 102 /60 mm Hg Heart rate 58/ min
Respiratory rate 14/min
Oxygen saturation 92% on room air
Diagnostic Results
0800:
Cortisol (serum) 16 mcg/dL (5 to 23 mcg/dL)
Serum T3 60 ng/dL (70 ng/dL to 205 ng/dL)
Serum T4 (total) 3 mcg/dL (5 mcg/dL to 12 mcg/dL)
Question 5 of 5
A nurse in the emergency department is caring for a female client brought to the ER by family for fatigue. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: Hypothyroidism, Request a prescription for Thyroid hormone replacement, Administer supplemental oxygen, Bowel function, Oxygen saturation
Rationale: The client exhibits signs consistent with hypothyroidism, including fatigue, weight gain, decreased appetite, hair loss, constipation, and intolerance to cold. The laboratory results show low serum T3 and T4 levels, confirming this diagnosis. Requesting a prescription for thyroid hormone replacement and administering supplemental oxygen address the condition, while monitoring bowel function and oxygen saturation assesses progress.