ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
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: C
Rationale: Decorticate posturing involves pronation of the hands with arms bent toward the chest, indicating brain damage. Other options describe decerebrate posturing or are incorrect.
Question 2 of 5
An older adult client in an orthopedic unit has an intracapsular fracture of the right hip following a fall. The client is in Buck's traction and will have hip prosthesis surgery in the morning. The nurse should reinforce with the client that this type of traction promotes which of the following outcomes?
Correct Answer: D
Rationale: Buck’s traction relieves muscle spasms by applying gentle pressure to align the fracture. It does not reduce the fracture or involve pins.
Question 3 of 5
A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Raising the head of the bed lowers blood pressure, reducing the risk of complications like stroke in autonomic dysreflexia. Checking for causes follows this immediate action.
Question 4 of 5
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
Correct Answer: A,D,E
Rationale: Applying a compression bandage reduces swelling and supports the injured area. Elevating the foot promotes venous return to decrease swelling. Checking toes for color, temperature, and sensation assesses for nerve or vascular damage. Heat can increase swelling and inflammation, and encouraging range of motion may worsen the injury.
Question 5 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.