ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?
Correct Answer: C
Rationale: difficulty speaking is the priority assessment finding because it indicates a worsening of the client's neurological status and a possible increase in intracranial pressure.
Question 2 of 5
When providing education to a student nurse about ways to avoid increased intracranial pressure, which of the following will the nurse include in the instructions? (Select All that Apply.)
Correct Answer: A,B,C,D
Rationale: Consulting with dietary to manage fluid and sodium intake, keeping the head at 25 degrees or lower to promote venous drainage, dimming lights to reduce stimulation, and ordering a stool softener to prevent straining are all measures to avoid increased ICP.
Question 3 of 5
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
Correct Answer: B
Rationale: Suctioning saliva from the client's mouth is the highest priority intervention, as it can prevent aspiration and maintain a patent airway.
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: A
Rationale: A GCS score of 3 for eye opening indicates that the client opens their eyes in response to speech.
Question 5 of 5
A client who recently suffered a stroke suffers from leftsided homonymous hemianopsia. What action does the nurse take when caring for the client during meal time?
Correct Answer: C
Rationale: Sit with the client at each meal and explain where to find the food. This would help the client orient themselves to their surroundings and locate their food using verbal cues and guidance from the nurse.