ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A nurse is monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply
Correct Answer: B,C,D,E
Rationale: Stage 3 ICP is characterized by hypotension, widened pulse pressure, bradycardia with a bounding pulse, and uneven breathing due to severe brain compression.
Question 2 of 5
An 84year old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?
Correct Answer: D
Rationale: Subacute subdural hematoma: This is correct because subacute subdural hematomas occur within 2 to 14 days of head trauma and cause gradual and fluctuating changes in mental status, which may be mistaken for dementia or delirium.
Question 3 of 5
A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis. Assessment findings include nuchal rigidity and a petechial rash. After Implementing droplet precautions, which of the following actions should the nurse initiate next?
Correct Answer: B
Rationale: Assessing cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.
Question 4 of 5
A nurse is preparing to administer intravenous mannitol, an osmotic diuretic, to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
Correct Answer: B
Rationale: Reduce edema of the brain is the purpose of the medication because mannitol works by creating an osmotic gradient between the blood and the脳 tissue, drawing excess fluid out of the brain cells and into the blood vessels.
Question 5 of 5
A nurse is caring for a client who has rightsided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Placing suction equipment at the client's bedside is a correct action for a nurse to take when caring for a client who has impairment of cranial nerves IX and X, which control swallowing and prevent aspiration.