RN ATI Fundamentals of Nursing | Nurselytic

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Question 1 of 5

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min,respiratory rate 24/min BP 132/76 mm Hg and temperature 36.8°C (98.2°F). Which of the following actions should the nurse perform?

Correct Answer: C

Rationale: The correct answer is C: Complete a neurological check. The client's sudden confusion and drowsiness indicate a neurological issue. A neurological check will help assess the client's cognitive status, motor function, and sensory perception. Holding digoxin (
A) is not indicated as the client's symptoms are not consistent with digoxin toxicity. Increasing fluid intake (
B) is not relevant to the client's neurological symptoms. Administering antihypertensive medication (D, E) is not appropriate without further assessment of the client's neurological status. Completing a neurological check (
C) is the priority to determine the underlying cause of the client's sudden change in mental status.

Question 2 of 5

Correct Answer:

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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