ATI RN
ATI Custom Medical Surgical Nurse Exam 2 Questions
Extract:
Question 1 of 5
A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Avoiding strenuous activities for a week prevents further injury and supports recovery. Heat can worsen swelling, frequent questioning may be unnecessary, and encouraging prolonged sleep could mask worsening symptoms.
Question 2 of 5
A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?
Correct Answer: D
Rationale: Clear fluid in the ear may indicate a cerebrospinal fluid leak, a serious complication of head injury requiring immediate attention. Bruising, disorientation, and tachycardia, while concerning, are less urgent.
Question 3 of 5
A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?
Correct Answer: C
Rationale: Chronic atrial fibrillation increases the risk of ischemic embolic stroke due to clot formation in the heart. Other conditions may cause different stroke types.
Question 4 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 GCS score of 3 for eye-opening indicates the client opens their eyes in response to voice, making option D correct. The client is not unconscious, can make vocal sounds (verbal score of 5), and may not follow commands (motor score of 5 indicates localizing pain).
Question 5 of 5
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
Correct Answer: C,D,E
Rationale: Night lights improve visibility, a reachable bedside table reduces unnecessary movement, and locked wheels ensure stability, all reducing fall risk. Sedatives and bed height do not directly prevent falls.