ATI RN
ATI Custom MS Nurse Questions
Extract:
Client who fell at home and reported a brief loss of consciousness
Question 1 of 5
A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?
Correct Answer: D
Rationale: The nurse should immediately report small drops of clear fluid in the left ear to the charge nurse. This finding could indicate a cerebrospinal fluid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.
Extract:
Client who sustained a minor head injury earlier in the day
Question 2 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.
Extract:
Client on the floor in the clonic phase of a tonic-clonic seizure
Question 3 of 5
A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?
Correct Answer: D
Rationale: The nurse should place a pillow under the client's head if the client is on the floor in the clonic phase of a tonic-clonic seizure. This can help protect the client's head from injury during the seizure.
Extract:
Client restless following a traumatic brain injury with increased intracranial pressure
Question 4 of 5
A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?
Correct Answer: C
Rationale: An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure.
Extract:
Client difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure
Question 5 of 5
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?
Correct Answer: B
Rationale: The nurse should use the term 'postictal phase' when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.