ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
Correct Answer: B,D
Rationale: Bradycardia and nonreactive dilated pupils are late signs of increased ICP, indicating brainstem compression or herniation.
Extract:
Medical History
Client reports falling and hitting their head and right shoulder after slipping on a wet floor yesterday. Denies loss of consciousness. Complains of pain in right shoulder. Has taken both acetaminophen and ibuprofen for pain with minimal relief obtained. Stayed up entire night playing video games yesterday to distract self from pain. Reports intermittent nausea and vomiting.
Vital Signs
• Oral temperature 37.5° C (99.6° F)
• Heart rate 76/min and regular
• Respiratory rate 20/min even and unlabored
• Blood pressure 112/70 mm Hg in left arm
• Pulse oximetry 98% on room air
Nurses' Notes
0900:
Reports pain in right shoulder. Limited range of motion noted. Rates pain as 7 on a scale of 0 to
Denies numbness and tingling in arm. No swelling or bruising over the shoulder. Fingers warm with capillary refill time less than 3 seconds, sensation intact. Drowsy. Oriented to person. place, and time. Irritable and restless at times. PERRLA. Glascow score of 15. No hematomas noted on head. No nausea or vomiting at this time.
1000:
Continues to report pain in right shoulder. Pain increased from 7 to 8 on a scale of 0 to 10. Increased drowsiness noted. Glascow unchanged.
Question 2 of 5
Complete the following sentence by using the list of options. The nurse should first address the client's........ followed by the client's........
Correct Answer: A,E
Rationale: Drowsiness may indicate neurological deterioration post-head injury, requiring priority assessment, followed by addressing shoulder pain to support recovery.
Extract:
Admission Assessment
Today:
0800:
The client states, "I got admitted because they said I have a really bad UTI."
The client reports dysuria for "about three days." The client developed fever this morning, so
they came to the emergency department to be evaluated. The client was found to have a urinary tract infection and was admitted for further care. They state they are still having bladder discomfort, but reports no other manifestations.
Medical history Hypertension, atrial fibrillation
Current Medications lisinopril 40mg PO daily, warfarin 2.5 mg PO daily
The client is in no acute distress. Oropharynx clear, mucous membranes moist, breath sounds clear bilaterally. Heart rate with regular rhythm and no murmur. CN II-XII intact, no weakness.
Nurses' Notes
Today:
0900:
The nurse is called to the client's room. The client reports headache with pain of 4 on a pain scale of 0 to 10 as throbbing. "I think my fever is better, but my head is killing me. Can I have something stronger for pain?"
0945:
The nurse is called again to the client's room. The client states, "You've got to help, something is wrong; this is the worst headache of my life." Client also reports ringing in the ears, photophobia, and left-sided weakness. They deny facial pain .
Client crying aphasia observed; oropharynx clear, mucous membranes moist, loss of peripheral vision. Breath sounds clear bilaterally; heart rate with regular rate, no murmur; negative Kernig and Brudzinski sign, left-sided upper and lower extremity weakness.
Provider Prescriptions
Today:
0800:
Acetaminophen 650mg PO every 8 hr PRN fever greater than 38˚C (100.4˚F) Hydrocodone/Ibuprofen 7.5/200 mg PO every 8 hr PRN pain
Lisinopril 40mg PO daily Warfarin 2.5 mg PO daily
Ciprofloxacin 500 mg PO BID x 7 days
Laboratory Results
Today:
0800:
WBC 11,000 mm3 (5,000 to 10,00mm3)
Urinalysis
Appearance clear
Color dark amber
pH 6 (4.6 to 8)
Protein 2 mg/dL (0 to 8 mg/dL)
Leukocyte esterase positive
Nitrites positive
Ketones none
Bilirubin none
Blood positive
INR: 4.9 (0.8 to 1.1)
Vital Sign
Today:
0800:
Temperature 38.1˚C (100.5˚F)
Heart Rate 89/min
Respiratory Rate 19/min
Blood Pressure 119/85 mmHg
SaO2 98% on room air
0930:
Temperature 37.2˚C (98.9˚F)
Heart Rate 62/min
Respiratory Rate 19/min
Blood Pressure 159/83 mmHg
SaO2 93% on room air
Medication Administration Record
0800:
Acetaminophen 650 mg PO 0900:
Hydrocodone/Ibuprofen 7.5/200 mg PO
Question 3 of 5
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: B (Hemorrhagic Stroke), A (Prepare for STAT CT, Seizure precautions), C (Temperature, PT/INR)
Rationale: Sudden severe headache, neurological symptoms, and elevated INR suggest hemorrhagic stroke, requiring urgent CT and seizure precautions, with monitoring of temperature and PT/INR.
Extract:
Question 4 of 5
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
Correct Answer: B,D
Rationale: Bradycardia and nonreactive dilated pupils are late signs of increased ICP, indicating brainstem compression or herniation.
Extract:
Vital Signs
1230:
• Temperature 98.9˚F (37.2˚C)
• Heart Rate 70 /min
• Respiratory Rate 18 /min
• Blood Pressure 130/90 mm Hg
• Oxygen Saturation 99% on room air
• Pain score 0/10
1330:
• Temperature 99.9˚F (37.8˚C) Heart Rate 52 /min
• Respiratory Rate 32/min
• Blood Pressure 154/83mm Hg
• Oxygen Saturation 95% on room air
• Pain score 4/10
1430:
• Temperature 100.4˚F (38˚C)
• Heart Rate 40 /min
• Respiratory Rate 50/min
• Blood Pressure 190/40 mmHg
• Oxygen Saturation 97% on room air
• Pain score 9/10
Nurses' Notes
1230:
A nurse was called to the bedside and found the client on the floor. The client states: "I fell out of bed trying to get to the bathroom." They deny pain and are alert, and oriented to person, place, and time. Lungs clear to auscultation. Heart sounds S1, S2 heard. AROM of all extremities.
Glasgow coma scale 15. Provider notified. 1300:
Client states, "my head hurts." They are anxious and alert. Grimacing when moving their head. Glasgow coma scale 15. Provider notified.
1400:
Client experiencing Tonic-clonic seizure noted for approximately 1 minute. Airway maintained throughout. Client denies a history of seizures. Provider notified and at the bedside. Glasgow Coma Scale 14. Client is not oriented to time.
1430:
The client states "I'm scared I'm going to die! My head really hurts." Client is agitated and restless. Lungs sounds are clear to auscultation; however, their heart rate is irregular. Client is bradycardic. The client is experiencing weakness on the right side of their body. Their right eye pupil is dilated, and their left eye pupil is reactive to light. Oriented to person and place. Glasgow coma scale 13. They are confused and unable to follow commands.
Question 5 of 5
Complete the following sentence by using the lists of options. The client is at highest risk for developing...... as evidenced by the client's.......
Correct Answer: B,D
Rationale: Bradycardia and neurological symptoms post-fall suggest intracranial hemorrhage, with heart rate indicating increased ICP.