ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
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: Clear fluid in the ear may indicate a cerebrospinal fluid leak, a serious complication of head injury requiring immediate attention. Bruising, disorientation, and tachycardia, while concerning, are less urgent.
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: Avoiding strenuous activities for a week prevents further injury and supports recovery. Heat can worsen swelling, frequent questioning may be unnecessary, and encouraging prolonged sleep could mask worsening symptoms.
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: Placing a pillow under the head protects the client from head injury during a seizure. Inserting objects, restraining, or forcing a supine position can cause harm or worsen the seizure.
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: Reducing stimuli (e.g., noise, light, visitors) calms the client and prevents further increases in intracranial pressure. Opioids, restraints, or complete darkness may be inappropriate or less effective.
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 postictal phase follows a seizure, characterized by difficulty arousing and sleepiness. Absence seizures, automatisms, and aura phase do not describe this state.