ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?
Correct Answer: B
Rationale: Administering lorazepam IV is the first-line treatment to terminate continuous seizures, prioritizing seizure cessation to prevent complications.
Question 2 of 5
Which problem should the nurse expect for a patient who has a positive Romberg test result?
Correct Answer: D
Rationale: A positive Romberg test indicates impaired balance and proprioception, increasing the risk of falls due to difficulty maintaining stability.
Question 3 of 5
A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)
Correct Answer: B,D
Rationale: Oxygen and suction setups are essential for managing respiratory complications and airway clearance during seizures, enhancing patient safety.
Question 4 of 5
The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?
Correct Answer: A
Rationale: Cushing's triad (hypertension, bradycardia, irregular respirations) is characteristic of increased intracranial pressure, reflecting brainstem compression.
Extract:
Admission Assessment
Today:
0800:
The client states, "I got admitted because they said I have a really bad UTI."
The client reports dysuria for "about three days." The client developed fever this morning, so
they came to the emergency department to be evaluated. The client was found to have a urinary tract infection and was admitted for further care. They state they are still having bladder discomfort, but reports no other manifestations.
Medical history Hypertension, atrial fibrillation
Current Medications lisinopril 40mg PO daily, warfarin 2.5 mg PO daily
The client is in no acute distress. Oropharynx clear, mucous membranes moist, breath sounds clear bilaterally. Heart rate with regular rhythm and no murmur. CN II-XII intact, no weakness.
Nurses' Notes
Today:
0900:
The nurse is called to the client's room. The client reports headache with pain of 4 on a pain scale of 0 to 10 as throbbing. "I think my fever is better, but my head is killing me. Can I have something stronger for pain?"
0945:
The nurse is called again to the client's room. The client states, "You've got to help, something is wrong; this is the worst headache of my life." Client also reports ringing in the ears, photophobia, and left-sided weakness. They deny facial pain .
Client crying aphasia observed; oropharynx clear, mucous membranes moist, loss of peripheral vision. Breath sounds clear bilaterally; heart rate with regular rate, no murmur; negative Kernig and Brudzinski sign, left-sided upper and lower extremity weakness.
Provider Prescriptions
Today:
0800:
Acetaminophen 650mg PO every 8 hr PRN fever greater than 38˚C (100.4˚F) Hydrocodone/Ibuprofen 7.5/200 mg PO every 8 hr PRN pain
Lisinopril 40mg PO daily Warfarin 2.5 mg PO daily
Ciprofloxacin 500 mg PO BID x 7 days
Laboratory Results
Today:
0800:
WBC 11,000 mm3 (5,000 to 10,00mm3)
Urinalysis
Appearance clear
Color dark amber
pH 6 (4.6 to 8)
Protein 2 mg/dL (0 to 8 mg/dL)
Leukocyte esterase positive
Nitrites positive
Ketones none
Bilirubin none
Blood positive
INR: 4.9 (0.8 to 1.1)
Vital Sign
Today:
0800:
Temperature 38.1˚C (100.5˚F)
Heart Rate 89/min
Respiratory Rate 19/min
Blood Pressure 119/85 mmHg
SaO2 98% on room air
0930:
Temperature 37.2˚C (98.9˚F)
Heart Rate 62/min
Respiratory Rate 19/min
Blood Pressure 159/83 mmHg
SaO2 93% on room air
Medication Administration Record
0800:
Acetaminophen 650 mg PO 0900:
Hydrocodone/Ibuprofen 7.5/200 mg PO
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: B (Hemorrhagic Stroke), A (Prepare for STAT CT, Seizure precautions), C (Temperature, PT/INR)
Rationale: Sudden severe headache, neurological symptoms, and elevated INR suggest hemorrhagic stroke, requiring urgent CT and seizure precautions, with monitoring of temperature and PT/INR.