ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action?
Correct Answer: C
Rationale: New-onset leg weakness suggests spinal cord compression, requiring urgent intervention to prevent permanent neurological damage.
Question 2 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:
Nurses' Notes
Client admitted to the emergency department with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, and general muscle aches. The client reports diarrhea, abdominal pain, and a sore throat. Pupils are 3 mm, equal and reactive to light. Intermittent nystagmus noted. Client reports sensitivity to light.
Client is lethargic, but arouses easily and is oriented to person, place, and time. Hand grasps are strong and equal bilaterally.
Bilateral breath sounds are clear and present throughout. Apical pulse is regular.
Skin is warm and dry. Pinpoint, red, macular rash noted on upper chest. Abdomen is distended, bowel sounds are present in 4 quadrants.
Vital Signs
Temperature 38.9° C (102° F)
Blood pressure 168/80 mm Hg
Heart rate 118/min
Respiratory rate 24/min
Oxygen saturation 95% on room air
Question 3 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: B (Meningitis), A (Seizure precautions, Dim lights), C (Neurologic status, Temperature)
Rationale: Symptoms like headache, photophobia, and rash suggest meningitis, requiring seizure precautions and light reduction, with monitoring of neurologic status and temperature.
Extract:
Question 4 of 5
A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?
Correct Answer: C
Rationale: Assessing the client's symptoms is crucial to monitor for stroke progression and guide interventions, especially with changing vital signs.
Question 5 of 5
The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?
Correct Answer: B
Rationale: Maintaining cervical spine precaution prevents further spinal cord injury in trauma patients until spinal injury is ruled out.