ATI RN
ATI Med Surg Adult Care 2 Questions
Extract:
Question 1 of 5
When providing education to a student nurse about ways to avoid increased intracranial pressure, which of the following will the nurse include in the instructions? (Select All that Apply.)
Correct Answer: A,B,C,D
Rationale: Consulting with dietary to manage fluid and sodium intake, keeping the head at 25 degrees or lower to promote venous drainage, dimming lights to reduce stimulation, and ordering a stool softener to prevent straining are all measures to avoid increased ICP.
Question 2 of 5
A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.
Correct Answer: B,C,D
Rationale: Increased ICP leads to ischemia due to reduced cerebral perfusion, hypotension as a late compensatory mechanism, and hyperventilation as a respiratory response to acidosis.
Question 3 of 5
A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?
Correct Answer: C
Rationale: Complex partial. This is correct because complex partial seizures involve impaired consciousness and automatisms, such as lip smacking, chewing, or fidgeting. They may also involve focal motor activity, such as twitching of one side of the face or body.
Question 4 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: This is correct because clear fluid draining from the nose could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication of head trauma. Allowing the drainage to drip onto a sterile gauze pad can help confirm the presence of CSF by observing a halo sign.
Question 5 of 5
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?
Correct Answer: C
Rationale: Widened pulse pressure is the difference between systolic and diastolic blood pressure, which increases as a compensatory mechanism to maintain cerebral perfusion in the face of increased ICP.