ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
After performing a neurological assessment, the student nurse shares the following findings with the primary nurse: Visual fields full to confrontation with Intact extraocular movements. No nystagmus, midline protrusion of tongue, and negative Romberg test. Which of the following will the primary nurse tell the student nurse to document?
Correct Answer: B
Rationale: This choice is correct because the findings indicate that the visual fields, extraocular movements, cranial nerves IX and XII (glossopharyngeal and hypoglossal), and vestibular function are normal.
Question 2 of 5
The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?
Correct Answer: A
Rationale: This is the correct answer because a fixed dilated pupil indicates compression of cranial nerve III, which is an early sign of increased intracranial pressure.
Question 3 of 5
A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?
Correct Answer: A
Rationale: Increasing fluid intake can help replenish cerebrospinal fluid (CSF) that was lost during the lumbar puncture, which can reduce the pressure difference between the brain and spinal cord that causes the headache.
Question 4 of 5
A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?
Correct Answer: C
Rationale: Complex partial. This is correct because complex partial seizures involve impaired consciousness and automatisms, such as lip smacking, chewing, or fidgeting. They may also involve focal motor activity, such as twitching of one side of the face or body.
Question 5 of 5
A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: Elevating side rails, placing the bed in the lowest position, providing suction, and keeping oxygen at the bedside are all appropriate interventions to ensure safety and manage potential complications during a seizure.