ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?
Correct Answer: B
Rationale: Cranial nerve III controls eye movements, and assessing up-and-down gaze tests its function.
Question 2 of 5
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?
Correct Answer: D
Rationale: Decorticate posturing involves flexion of the arms, wrists, and fingers with the arms held tightly to the chest, indicating cerebral hemisphere or corticospinal tract damage. Plantar flexion of the legs is not typical but is associated with decerebrate posturing.
Question 3 of 5
Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?
Correct Answer: C
Rationale: Respiratory assessment is critical due to the risk of impaired breathing from C5-level injury affecting the diaphragm.
Question 4 of 5
A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?
Correct Answer: C
Rationale: Assessing the client's symptoms is crucial to monitor for stroke progression and guide interventions, especially with changing vital signs.
Question 5 of 5
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?
Correct Answer: B
Rationale: Timing and documenting seizure details are critical for accurate assessment and management, ensuring patient safety without harmful interventions like restraint or airway insertion.