ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Vital Signs
1230:
• Temperature 98.9˚F (37.2˚C)
• Heart Rate 70 /min
• Respiratory Rate 18 /min
• Blood Pressure 130/90 mm Hg
• Oxygen Saturation 99% on room air
• Pain score 0/10
1330:
• Temperature 99.9˚F (37.8˚C) Heart Rate 52 /min
• Respiratory Rate 32/min
• Blood Pressure 154/83mm Hg
• Oxygen Saturation 95% on room air
• Pain score 4/10
1430:
• Temperature 100.4˚F (38˚C)
• Heart Rate 40 /min
• Respiratory Rate 50/min
• Blood Pressure 190/40 mmHg
• Oxygen Saturation 97% on room air
• Pain score 9/10
Nurses' Notes
1230:
A nurse was called to the bedside and found the client on the floor. The client states: "I fell out of bed trying to get to the bathroom." They deny pain and are alert, and oriented to person, place, and time. Lungs clear to auscultation. Heart sounds S1, S2 heard. AROM of all extremities.
Glasgow coma scale 15. Provider notified. 1300:
Client states, "my head hurts." They are anxious and alert. Grimacing when moving their head. Glasgow coma scale 15. Provider notified.
1400:
Client experiencing Tonic-clonic seizure noted for approximately 1 minute. Airway maintained throughout. Client denies a history of seizures. Provider notified and at the bedside. Glasgow Coma Scale 14. Client is not oriented to time.
1430:
The client states "I'm scared I'm going to die! My head really hurts." Client is agitated and restless. Lungs sounds are clear to auscultation; however, their heart rate is irregular. Client is bradycardic. The client is experiencing weakness on the right side of their body. Their right eye pupil is dilated, and their left eye pupil is reactive to light. Oriented to person and place. Glasgow coma scale 13. They are confused and unable to follow commands.
Question 1 of 5
Complete the following sentence by using the lists of options. The client is at highest risk for developing...... as evidenced by the client's.......
Correct Answer: B,D
Rationale: Bradycardia and neurological symptoms post-fall suggest intracranial hemorrhage, with heart rate indicating increased ICP.
Extract:
Question 2 of 5
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?
Correct Answer: B
Rationale: Timing and documenting seizure details are critical for accurate assessment and management, ensuring patient safety without harmful interventions like restraint or airway insertion.
Question 3 of 5
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Small bites reduce choking risk and facilitate safer swallowing in clients with dysphagia.
Question 4 of 5
A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?
Correct Answer: C
Rationale: Rest periods help manage fatigue, a common MS symptom, supporting energy conservation for clients with neurological symptoms.
Question 5 of 5
Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?
Correct Answer: B
Rationale: Administering lorazepam IV is the first-line treatment to terminate continuous seizures, prioritizing seizure cessation to prevent complications.