ATI RN
ATI EW N300 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?
Correct Answer: A
Rationale: High systolic BP, bradycardia, and low respiratory rate suggest Cushing's triad, indicative of increased ICP.
Question 2 of 5
A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?
Correct Answer: C
Rationale: Lowering the head of the bed counters orthostatic hypotension, common in spinal cord injury patients, and vital signs guide further interventions.
Question 3 of 5
The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?
Correct Answer: A
Rationale: Restlessness and altered mental status are early signs of increasing ICP due to cerebral edema.
Question 4 of 5
The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?
Correct Answer: C
Rationale: Pointing out unacceptable behavior sets clear boundaries and educates the patient on appropriate conduct.
Question 5 of 5
A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube. For safe administration, the nurse should:
Correct Answer: C
Rationale: Abdominal distention, hypoactive bowel sounds, and RLQ tenderness suggest possible ileus or obstruction, requiring discussion with the prescriber for safe feeding.