ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 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.
Question 2 of 5
Which of the following clients is most at risk for traumatic brain injury?
Correct Answer: C
Rationale: A 18year old highschool graduate who is enrolling in the Army: This is correct because military personnel are at high risk of traumatic brain injury due to exposure to blasts, projectiles, falls, and assaults.
Question 3 of 5
A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?
Correct Answer: A
Rationale: This is the correct answer because cranial nerve II is the optic nerve, which is responsible for vision. Testing the client's ability to look up and down without moving his head assesses the function of this nerve.
Question 4 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 5 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: This is correct because clear fluid draining from the nose could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication of head trauma. Allowing the drainage to drip onto a sterile gauze pad can help confirm the presence of CSF by observing a halo sign.