ATI RN
ATI Med Surg Adult Care 2 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: A
Rationale: A GCS score of 3 for eye opening indicates that the client opens their eyes in response to speech.
Question 2 of 5
A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10. What additional finding indicates that he has suffered a basilar skull fracture?
Correct Answer: C
Rationale: Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture.
Question 3 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 4 of 5
A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: Elevating side rails, placing the bed in the lowest position, providing suction, and keeping oxygen at the bedside are all appropriate interventions to ensure safety and manage potential complications during a seizure.
Question 5 of 5
When caring for the client with Alzheimer's disease, which of the following are appropriate items to include in the client's room?
Correct Answer: D
Rationale: Clocks, calendar, family photos are appropriate items to include in the room of a client with Alzheimer's disease. They can help the client maintain orientation to time, place, and person, and provide comfort and familiarity.