ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?
Correct Answer: A
Rationale: Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration. Identifying and treating the cause can help resolve the delirium and prevent further complications.
Question 2 of 5
A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10. What additional finding indicates that he has suffered a basilar skull fracture?
Correct Answer: C
Rationale: Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture.
Question 3 of 5
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased Intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?
Correct Answer: A
Rationale: A decrease in the Glasgow Coma Score indicates a deterioration in the level of consciousness, which is a sign of increased ICP.
Question 4 of 5
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
Correct Answer: A
Rationale: A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would need total nursing care and close monitoring.
Question 5 of 5
An 84year old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?
Correct Answer: D
Rationale: Subacute subdural hematoma: This is correct because subacute subdural hematomas occur within 2 to 14 days of head trauma and cause gradual and fluctuating changes in mental status, which may be mistaken for dementia or delirium.