ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?
Correct Answer: A
Rationale: Cushing's triad (hypertension, bradycardia, irregular respirations) is characteristic of increased intracranial pressure, reflecting brainstem compression.
Question 2 of 5
The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?
Correct Answer: A
Rationale: Cushing's triad (hypertension, bradycardia, irregular respirations) is characteristic of increased intracranial pressure, reflecting brainstem compression.
Question 3 of 5
A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?
Correct Answer: C
Rationale: Positioning the patient laterally facilitates lumbar puncture and minimizes complications like post-dural puncture headache.
Question 4 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: D
Rationale: A low GCS score indicates severe neurological impairment, suggesting the client is unconscious.
Question 5 of 5
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. Which of the following complications should the nurse monitor the client for? (Select all that apply.)
Correct Answer: B,D
Rationale: Weakened gag reflex and hypotension are complications of cervical spinal cord injury due to impaired autonomic and cranial nerve function.