ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 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: Hypertension can indicate increased intracranial pressure post-craniotomy. Edema, diarrhea, and decreased pulses are not typical manifestations.
Question 2 of 5
While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?
Correct Answer: B
Rationale: A warm area on the cast suggests an underlying infection due to increased blood flow as the body fights the infection. Uneven cast drying, pressure, or poor circulation do not typically cause warmth.
Question 3 of 5
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?
Correct Answer: C
Rationale: Checking the temperature assesses for fever, a key symptom of meningitis, which may present with headache and stiff neck. Other actions follow based on findings.
Question 4 of 5
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
Correct Answer: C,D,E
Rationale: Night lights improve visibility, a reachable bedside table reduces unnecessary movement, and locked wheels ensure stability, all reducing fall risk. Sedatives and bed height do not directly prevent falls.
Question 5 of 5
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Correct Answer: C
Rationale: Suctioning saliva prevents aspiration and maintains a patent airway, which is critical for survival in an unconscious client. Other interventions are important but secondary to airway management.