ATI RN
ATI Adult Medical Surgical Assessment 2 Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)
Correct Answer: A,B,C
Rationale: Infection is a significant risk with ventriculostomy drains due to the invasive nature of the procedure. Vomiting and widening pulse pressure can indicate increased intracranial pressure, a serious complication requiring immediate attention. Equal pupils and normal ICP readings are not complications.
Question 2 of 5
A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Assessing the pain's characteristics and intensity first guides appropriate pain management interventions tailored to the client's needs.
Question 3 of 5
A nurse is assessing a client who has had a left-hemisphere stroke. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Expressive aphasia results from left-hemisphere strokes, impairing speech production due to damage in language areas.
Question 4 of 5
A nurse is planning care for a client who has Ménière's disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?
Correct Answer: D
Rationale: A low-sodium diet helps reduce fluid retention in the body, which can decrease the pressure in the inner ear and help manage the symptoms of Ménière's disease. Reducing sodium intake to 1,500-2,000 milligrams per day is often recommended.
Question 5 of 5
A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?
Correct Answer: A
Rationale: Providing assistance with ambulation prevents falls due to ataxia, a common symptom of cerebellar tumors affecting coordination and balance.