ATI RN
ATI Med Surg Exam 1 2024 Questions
Extract:
Question 1 of 5
Which of the following should the nurse expect to find?
Correct Answer: A
Rationale: A low intraocular pressure reading may indicate a detached retina, as the vitreous humor may leak into the space behind the retina, causing a decrease in intraocular pressure. Further diagnostic tests are needed for confirmation.
Question 2 of 5
A nurse is teaching a client who has pericarditis. Which of the following statements should the nurse include in the client teaching to explain the cause of pericarditis?
Correct Answer: D
Rationale: Pericarditis results from inflammation of the pericardium, causing stiffening that restricts heart movement and leads to chest pain, distinguishing it from conditions affecting ventricular tissue.
Question 3 of 5
A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?
Correct Answer: C
Rationale: Hyperventilation is a potential intervention for managing brain herniation as it helps temporarily lower intracranial pressure (ICP) by inducing cerebral vasoconstriction. By increasing the rate and depth of breathing, hyperventilation reduces the partial pressure of carbon dioxide (PaCO2) in the blood, leading to vasoconstriction of cerebral blood vessels and a decrease in cerebral blood flow. This can help alleviate symptoms associated with increased ICP and reduce the risk of further brain injury.
Question 4 of 5
A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)
Correct Answer: C,D,E
Rationale: Changes to pupil size and shape, swelling of the optic nerve (papilledema), and decreasing Glasgow Coma scores are direct indicators of worsening intracranial pressure due to brainstem compression, optic disc congestion, and deteriorating consciousness. A normal respiratory rate (12/min) and blood pressure (108/74 mm Hg) do not indicate worsening in this context.
Question 5 of 5
A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological changes should the nurse educate the client and family to monitor?
Correct Answer: A,B,C,D,E
Rationale: All listed changes are relevant: weight loss may result from reduced appetite or swallowing issues; decreased mobility reflects functional decline; increased physical activity may indicate restlessness or wandering; unkempt appearance signals self-care challenges; constipation is common due to reduced activity or medication side effects.