ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: D
Rationale: A low GCS score indicates severe neurological impairment, suggesting the client is unconscious.
Question 2 of 5
A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?
Correct Answer: B
Rationale: Phenytoin is associated with gingival hyperplasia, making inspection of the oral mucosa critical for detecting this adverse effect.
Question 3 of 5
Which problem should the nurse expect for a patient who has a positive Romberg test result?
Correct Answer: D
Rationale: A positive Romberg test indicates impaired balance and proprioception, increasing the risk of falls due to difficulty maintaining stability.
Question 4 of 5
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Turning the client's head to the side prevents aspiration by allowing secretions or vomitus to drain, prioritizing airway protection during a seizure.
Question 5 of 5
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
Correct Answer: B
Rationale: Checking respiratory rate and effort ensures adequate oxygenation, prioritizing airway and breathing in suspected stroke cases.