ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Nurses' Notes
Client admitted to the emergency department with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, and general muscle aches. The client reports diarrhea, abdominal pain, and a sore throat. Pupils are 3 mm, equal and reactive to light. Intermittent nystagmus noted. Client reports sensitivity to light.
Client is lethargic, but arouses easily and is oriented to person, place, and time. Hand grasps are strong and equal bilaterally.
Bilateral breath sounds are clear and present throughout. Apical pulse is regular.
Skin is warm and dry. Pinpoint, red, macular rash noted on upper chest. Abdomen is distended, bowel sounds are present in 4 quadrants.
Vital Signs
Temperature 38.9° C (102° F)
Blood pressure 168/80 mm Hg
Heart rate 118/min
Respiratory rate 24/min
Oxygen saturation 95% on room air
Question 1 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: B (Meningitis), A (Seizure precautions, Dim lights), C (Neurologic status, Temperature)
Rationale: Symptoms like headache, photophobia, and rash suggest meningitis, requiring seizure precautions and light reduction, with monitoring of neurologic status and temperature.
Extract:
Question 2 of 5
A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, 'I cannot teach anymore. It will be too upsetting if I have a seizure at work.' How should the nurse respond to specifically address the patient's concern?
Correct Answer: C
Rationale: Reassuring the patient that epilepsy can often be controlled with medications directly addresses their fear of having a seizure at work, supporting their ability to continue teaching.
Question 3 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 4 of 5
What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel?
Correct Answer: B
Rationale: Clopidogrel inhibits platelet aggregation, reducing plaque formation in atherosclerosis, not dissolving existing clots.
Question 5 of 5
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
Correct Answer: B,D
Rationale: Bradycardia and nonreactive dilated pupils are late signs of increased ICP, indicating brainstem compression or herniation.