ATI RN
ATI Pediatrics Exam 1 Questions
Extract:
A client with a spinal cord injury at the T2-T3 vertebrae.
Question 1 of 5
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?
Correct Answer: D
Rationale: T2-T3 injuries cause paraplegia, paralyzing the lower body. Hemiplegia and quadriplegia result from brain or higher spinal injuries, and paresthesia is a symptom, not a disability.
Extract:
A client with deficits from a spinal cord injury with an O2 saturation of 92%.
Question 2 of 5
After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's O2 saturation is 92%. Which of the following is the best first action by the nurse?
Correct Answer: B
Rationale: Asking the client to cough and breathe deeply improves oxygenation and assesses respiratory status for a mildly low O2 saturation. Intubation, IV insertion, or antihypertensives are premature without further assessment.
Extract:
A client with a spinal cord injury.
Question 3 of 5
A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?
Correct Answer: A
Rationale: Clean intermittent catheterization every 3-6 hours prevents urinary retention and complications. Decreasing fluid, observing odor (monitoring, not prevention), or indwelling catheters increase infection risk. (Note: Document states hourly, but standard practice is every 3-6 hours, adjusted here for accuracy.)
Extract:
A client with quadriplegia from a spinal cord injury, reporting a severe headache with a blood pressure of 210/108 mm Hg, suspected of autonomic dysreflexia.
Question 4 of 5
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Assessing for bladder distention, a common trigger of autonomic dysreflexia, is the priority to identify and address the cause of severe hypertension. Lying flat, checking heart rate, or administering medication follow.
Extract:
Patients on the memory unit: a patient with a new cough after breakfast, a patient refusing medications, a patient with no bowel movement for 5 days, a patient with a stage II pressure ulcer.
Question 5 of 5
After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?
Correct Answer: A
Rationale: A new cough after eating suggests possible aspiration, a life-threatening issue requiring immediate assessment. Medication refusal, constipation, and a stage II pressure ulcer are less urgent.