ATI RN
ATI EW N300 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-PA). Which of the following symptoms would prompt the nurse to stop the infusion of t-PA?
Correct Answer: A,B,C
Rationale: Decreased consciousness, elevated blood pressure with headache, and vomiting with nausea suggest intracranial hemorrhage, a serious complication requiring immediate cessation of t-PA.
Question 2 of 5
The nurse is caring for a patient with a spinal cord injury at the level of C-7. The patient is having a severe headache, hypertension, bradycardia, diaphoresis, and flushing of the face with pale, cold skin below the level of the injury. What are the priority nursing interventions?
Correct Answer: A
Rationale: These interventions address autonomic dysreflexia by reducing blood pressure and removing triggers like catheter obstruction.
Question 3 of 5
The nurse is caring for a patient who has a spinal cord injury at the level of C-6. The patient displays the following symptoms: loss of motor function on the ipsilateral side of the injury, and loss of temperature and pain sensation on the contralateral side. What type of incomplete injury did this patient most likely suffer?
Correct Answer: A
Rationale: Brown-Sequard injury results in ipsilateral motor function loss and contralateral pain/temperature loss due to hemisection of the spinal cord.
Question 4 of 5
When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate an order for which of the following medications to manage increases in intracranial pressure (ICP)?
Correct Answer: B
Rationale: Hypertonic saline (3%) reduces ICP by drawing fluid from brain tissue into the bloodstream, effectively lowering intracranial pressure.
Question 5 of 5
The nurse is caring for a patient in the acute care setting with a spinal cord injury at the level of C-3. The nurse understands that the main cause of complications or death related to this injury includes:
Correct Answer: D
Rationale: Respiratory compromise due to diaphragm paralysis at C-3 is the primary cause of morbidity or mortality.