ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
Correct Answer: A
Rationale: Sumatriptan is contraindicated in patients with recent myocardial infarction due to its vasoconstrictive effects, posing a cardiovascular risk.
Question 2 of 5
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Assessing for bladder distention addresses the common trigger of autonomic dysreflexia, prioritizing the cause of the hypertensive crisis.
Question 3 of 5
Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?
Correct Answer: D
Rationale: Placing objects on the left side compensates for the visual deficit, promoting safety and independence.
Question 4 of 5
Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?
Correct Answer: C
Rationale: Respiratory assessment is critical due to the risk of impaired breathing from C5-level injury affecting the diaphragm.
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 5 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.