ATI Questions And Answers Neuro 2022-2023
Latest Update
Black Tag
The nurse should assign a black tag, or a class IV label, to clients who are not
... [Show More] expected to live and will be
allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and
indicate severely increased ICP. In a mass casualty situation, the overall goal is to provide lifesaving
treatment to the greatest number of people possible. - ANS-A nurse is triaging clients during a mass
casualty event. Which of the following labels should the nurse assign to a client who has a head injury with
fixed, dilated pupils?
A. Red Tag
B. Yellow Tag
C. Green Tag
D. Black Tag
A. Cerebellar dysfunction
Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive
Romberg sign. - ANS-A nurse asks a client to stand with her feet together and her eyes open. After a few
seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret
this finding as a positive Romberg test, indicating which of the following alterations?
A. Cerebellar dysfunction
B. Occipital lobe dysfunction
C. Increased intraocular pressure
D. Macular degeneration
C. Rigid skull containing cranial contents
The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and
bleeding from the head injury against the rigid skull results in an increase in ICP. - ANS-A nurse is caring
for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure
(ICP). This increase in ICP is due to which of the following?
A. Decreased cerebral perfusion
B. Leakage of cerebral spinal fluid
C. Rigid skull containing cranial contents
D. Brain herniated into the brainstem
C. The client is unable to understand words or sentences she hears.
Clients who cannot understand words or sentences they hear have receptive aphasia. - ANS-A nurse is
caring for a client who has receptive aphasia. Which of the following communication problems should the
nurse expect when assessing the client?
A. The client cannot name simple objects or formulate sentences or phrases.
B. The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue.
C. The client is unable to understand words or sentences she hears.
D. The client speaks words that substitute for those she intends to say.
A. Dysphagia
ABCs. - ANS-A nurse is providing teaching about degenerative complications to the partner of a client who
has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority?
A. Dysphagia
B. Emotional lability
C. Impaired speech
D. Self-Care dependency
A. A client who is difficult to arouse and is unable to respond to questions.
A client who is difficult to arouse and is unable to respond to questions could have decreased LOC due to
alcohol intoxication level or traumatic brain injury. The greatest risk to this client is the neurological
sequelae of head trauma or death due to severe alcohol intoxication. - ANS-A nurse in the emergency
department is caring for a group of clients who all have an odor of alcohol on their breath and multiple
injuries to the head and extremities. Which of the following clients should the nurse assess first?
A. A client who is difficult to arouse and is unable to respond to questions.
B. A client who has slurred speech and exhibits anger
C. A client who reports nausea and vomiting
D. A client who is uncooperative and has uncoordinated movements.
D. Limit choices offered to the client.
Choices should be limited for a client who has stage II AD to reduce confusion and frustration. - ANS-A
nurse is providing teaching to the family of a client who has stage II Alzheimer's Disease (AD). Which of the
following pieces of information should the nurse include in the teaching?
A. Place abstract pictures on the wall in the client's room.
B. Provide music for the client using headphones.
C. Reorient the client to reality frequently.
D. Limit choices offered to the client.
A. The client's ability to clear oral secretions.
ABCs - ANS-A nurse is caring for a client who is recovering from a recent stroke. Which of the following
assessments is the nurse's priority?
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