ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
Correct Answer: B
Rationale: Suctioning saliva from the client's mouth is the highest priority intervention, as it can prevent aspiration and maintain a patent airway.
Question 2 of 5
When considering the client with a neurocognitive deficit, the nurse understands that which of the following are excitatory neurotransmitters?
Correct Answer: B,C
Rationale: Norepinephrine and Dopamine are excitatory neurotransmitters that increase arousal, alertness, attention, motivation, reward, and movement.
Question 3 of 5
The nurse takes report on a client who was admitted with a severe headache, nausea, vomiting, photophobia, and a stiff neck. Which of the following is the priority intervention for the nurse to perform?
Correct Answer: C
Rationale: Administer penicillin. This is the priority intervention because it can treat bacterial meningitis, which is a life-threatening condition that requires immediate antibiotic therapy.
Question 4 of 5
An 84year old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?
Correct Answer: D
Rationale: Subacute subdural hematoma: This is correct because subacute subdural hematomas occur within 2 to 14 days of head trauma and cause gradual and fluctuating changes in mental status, which may be mistaken for dementia or delirium.
Question 5 of 5
A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?
Correct Answer: C
Rationale: Complex partial. This is correct because complex partial seizures involve impaired consciousness and automatisms, such as lip smacking, chewing, or fidgeting. They may also involve focal motor activity, such as twitching of one side of the face or body.