ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 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 2 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 3 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 4 of 5
A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?
Correct Answer: C
Rationale: tPA is contraindicated after 3 hours of stroke symptom onset, increasing bleeding risk without benefit.
Extract:
Vital Signs
1230:
• Temperature 98.9˚F (37.2˚C)
• Heart Rate 70 /min
• Respiratory Rate 18 /min
• Blood Pressure 130/90 mm Hg
• Oxygen Saturation 99% on room air
• Pain score 0/10
1330:
• Temperature 99.9˚F (37.8˚C) Heart Rate 52 /min
• Respiratory Rate 32/min
• Blood Pressure 154/83mm Hg
• Oxygen Saturation 95% on room air
• Pain score 4/10
1430:
• Temperature 100.4˚F (38˚C)
• Heart Rate 40 /min
• Respiratory Rate 50/min
• Blood Pressure 190/40 mmHg
• Oxygen Saturation 97% on room air
• Pain score 9/10
Nurses' Notes
1230:
A nurse was called to the bedside and found the client on the floor. The client states: "I fell out of bed trying to get to the bathroom." They deny pain and are alert, and oriented to person, place, and time. Lungs clear to auscultation. Heart sounds S1, S2 heard. AROM of all extremities.
Glasgow coma scale 15. Provider notified. 1300:
Client states, "my head hurts." They are anxious and alert. Grimacing when moving their head. Glasgow coma scale 15. Provider notified.
1400:
Client experiencing Tonic-clonic seizure noted for approximately 1 minute. Airway maintained throughout. Client denies a history of seizures. Provider notified and at the bedside. Glasgow Coma Scale 14. Client is not oriented to time.
1430:
The client states "I'm scared I'm going to die! My head really hurts." Client is agitated and restless. Lungs sounds are clear to auscultation; however, their heart rate is irregular. Client is bradycardic. The client is experiencing weakness on the right side of their body. Their right eye pupil is dilated, and their left eye pupil is reactive to light. Oriented to person and place. Glasgow coma scale 13. They are confused and unable to follow commands.
Question 5 of 5
Complete the following sentence by using the lists of options. The client is at highest risk for developing...... as evidenced by the client's.......
Correct Answer: B,D
Rationale: Bradycardia and neurological symptoms post-fall suggest intracranial hemorrhage, with heart rate indicating increased ICP.