ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Turning the client's head to the side is the first action that the nurse should take to prevent aspiration of saliva or vomitus and maintain a patent airway during a seizure.
Question 2 of 5
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?
Correct Answer: A,C
Rationale: A stroke involving the right hemisphere can impair the ability to recognize faces (prosopagnosia) and cause weakness or paralysis of the left side of the body (right hemiparesis).
Question 3 of 5
A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?
Correct Answer: A
Rationale: This is the correct answer because cranial nerve II is the optic nerve, which is responsible for vision. Testing the client's ability to look up and down without moving his head assesses the function of this nerve.
Question 4 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following is not an appropriate action for the nurse to take?
Correct Answer: B
Rationale: Placing the client's head on the nurse's lap may obstruct his airway and increase the risk of aspiration.
Question 5 of 5
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?
Correct Answer: B
Rationale: Restlessness is an early sign of increased ICP, indicating decreased cerebral oxygenation and impaired cognition.