ATI RN
ATI Custom MS Nurse Questions
Extract:
Client with increased intracranial pressure demonstrating decorticate posturing
Question 1 of 5
A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?
Correct Answer: D
Rationale: In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.
Extract:
Client in halo traction to immobilize cervical spine
Question 2 of 5
A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Elevating the head of the bed can help improve the patient's comfort and reduce the risk of complications such as aspiration in a client with halo traction.
Extract:
Older adult client 4 hr postoperative following an open reduction and internal fixation of a fractured femur
Question 3 of 5
A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: Checking capillary refill in the affected extremity every 4 hr is an important intervention to monitor the blood flow to the affected extremity and ensure that it is adequate.
Extract:
Client with a lower-leg cast reporting skin irritation around the upper edge
Question 4 of 5
A nurse is collecting data from a client who reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.
Extract:
Client 6 days post craniotomy for removal of an intracerebral aneurysm
Question 5 of 5
A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Correct Answer: D
Rationale: A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.