Questions 54

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ATI RN Test Bank

ATI Advanced Med Surg Cohort 4 Exam Questions

Extract:


Question 1 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 2 of 5

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer: A

Rationale: Turning the client's head to the side prevents aspiration by allowing secretions or vomitus to drain, prioritizing airway protection during a seizure.

Question 3 of 5

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Correct Answer: B

Rationale: Phenytoin is associated with gingival hyperplasia, making inspection of the oral mucosa critical for detecting this adverse effect.

Question 4 of 5

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Correct Answer: C

Rationale: Minimizing stimuli reduces stress and blood pressure, lowering the risk of aneurysm rupture.

Question 5 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.

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