ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following manifestations will the nurse expect to find? (Select all that apply.)
Correct Answer: B,D,F
Rationale:
Choice A Reason: Slow even breathing is not a sign of Cushing's Triad, which is a late indicator of increased intracranial pressure (ICP). The breathing pattern may be altered due to brainstem compression, but not necessarily slow or even.
Choice B Reason: This is a correct answer because bradycardia and bounding pulse are part of Cushing's Triad, which reflects an increased vagal tone and decreased cardiac output due to increased ICP.
Choice C Reason: Systolic hypotension with a narrowing pulse pressure is not a sign of Cushing's Triad, which involves an increased systolic blood pressure and a widened pulse pressure due to increased ICP. Hypotension may occur due to shock or hemorrhage, but not as a result of increased ICP.
Choice D Reason: This is a correct answer because irregular respirations are part of Cushing's Triad, which reflects impaired respiratory control due to brainstem compression from increased ICP. The respirations may be Cheyne-Stokes, central neurogenic hyperventilation, apneustic, or ataxic.
Choice E Reason: Tachycardia and bounding pulse are not signs of Cushing's Triad, which involves bradycardia and bounding pulse due to increased ICP. Tachycardia may occur due to pain, anxiety, fever, or hypoxia, but not as a result of increased ICP.
Choice F Reason: This is a correct answer because systolic hypertension with a widening pulse pressure are part of Cushing's Triad, which reflects an increased cerebral perfusion pressure due to increased ICP. The diastolic blood pressure remains stable or decreases, resulting in a widened pulse pressure.
Question 2 of 5
A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?
Correct Answer: A,B,D
Rationale: Standing next to the client aids hearing and allows seeing facial expressions (
Choice
A). Guiding away from background noise reduces distractions (
Choice
B). Repeating misunderstood phrases ensures comprehension (
Choice
D). Braille is for visual impairment, not hearing loss; large font or visuals are more appropriate (
Choice
C).
Question 3 of 5
A nurse is caring for a client who has suffered a stroke involving the left hemisphere. Which of the following alterations in function are consistent with this type of stroke?
Correct Answer: D
Rationale: Hemianopsia, the loss of vision in half of the visual field, is consistent with a left hemisphere stroke, which affects language, logic, and analysis, impacting reading, writing, and communication skills.
Question 4 of 5
A nurse is performing a Weber test on a client who reports difficulty hearing in his left ear. The client informs the nurse that he can hear the tone louder in his left ear. Which of the following does this result indicate?
Correct Answer: B
Rationale: In the Weber test, hearing the tone louder in the affected ear (left) indicates conductive hearing loss, due to sound wave blockage in the outer or middle ear (
Choice
B). The test is not inconclusive, as it shows lateralization (
Choice
A). Normal hearing shows no lateralization (
Choice
C). Sensorineural hearing loss causes lateralization to the unaffected ear (
Choice
D).
Question 5 of 5
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client reports a sudden increase in abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the best first action the nurse should take?
Correct Answer: C
Rationale: Notifying the healthcare provider is critical as these symptoms suggest a perforated appendix, a life-threatening condition requiring immediate intervention.