ATI RN
ATI Custom MS Nurse Questions
Extract:
Client with a traumatic head injury
Question 1 of 5
A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?
Correct Answer: A
Rationale: The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.
Extract:
Client with multiple sclerosis learning four-point alternate gait with crutches
Question 2 of 5
A nurse is reinforcing teaching with a client who has multiple sclerosis and is learning how to use the four-point alternate gait with crutches. Identify the order of the steps the nurse should give to the client.
Correct Answer: A,B,C,D
Rationale: The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait pattern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.
Extract:
Client difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure
Question 3 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.
Extract:
Client with a short arm cast for a fractured wrist
Question 4 of 5
A nurse is collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the affected arm?
Correct Answer: D
Rationale: Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments.
Extract:
Client with a Glasgow Coma Scale score of 8
Question 5 of 5
A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.