ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?
Correct Answer: D
Rationale: Decorticate posturing involves flexion of the arms, wrists, and fingers with the arms held tightly to the chest, indicating cerebral hemisphere or corticospinal tract damage. Plantar flexion of the legs is not typical but is associated with decerebrate posturing.
Question 2 of 5
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Impairment of cranial nerves IX and X increases aspiration risk due to impaired swallowing and gag reflex, necessitating suction equipment.
Question 3 of 5
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?
Correct Answer: A
Rationale: A spinal cord injury at T2-T3 typically results in paraplegia, affecting the lower extremities and possibly the trunk, due to the level of the lesion.
Question 4 of 5
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Turning the client's head to the side prevents aspiration by allowing secretions or vomitus to drain, prioritizing airway protection during a seizure.
Question 5 of 5
A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?
Correct Answer: B
Rationale: Phenytoin is associated with gingival hyperplasia, making inspection of the oral mucosa critical for detecting this adverse effect.