ATI RN
ATI Custom MS Nurse Questions
Extract:
Client with a spinal cord injury at T-4
Question 1 of 5
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
Correct Answer: C
Rationale:
To prevent autonomic dysreflexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreflexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest.
Extract:
Client with epilepsy experiencing a tonic-clonic seizure
Question 2 of 5
A nurse on a medical-surgical unit is checking the bowel sounds of a client who has epilepsy. The client begins to experience a tonic-clonic seizure. Identify the sequence of steps the nurse should follow.
Correct Answer: A,B,D,C
Rationale: The correct sequence of steps is: remain with the client and call for help, place the client in the lateral position, check the client for injuries, and reorient and reassure the client. This ensures safety, airway protection, and post-seizure care.
Extract:
Client with a spinal cord injury suspected of autonomic dysreflexia
Question 3 of 5
A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
Extract:
Client with a Glasgow Coma Scale score of 8
Question 4 of 5
A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.
Extract:
Client who sustained a minor head injury earlier in the day
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: The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.