Exam 4
ATI questions and answers
Chapters 3, 5-11, 14-16
Q&A
1
Chapter 3 Neurologic Diagnostic Procedures
1. A nurse is caring for a client whois
... [Show More] postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.)
A. Use the Glasgow Coma Scale when assessing the client.???
B. Assist the client to a supine position. C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
E. Instruct the client to perform deep breathing and coughing exercises.
2. A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension
3. A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10 B.E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15
D.E2 + V2 + M4 = 8
4. A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply.)
A. “I think I might be pregnant.” B. “I take warfarin.”
C. “I take antihypertensive medication.”
D. “I am allergic to shrimp.”
E. “I ate a light breakfast this morning.”
5. A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching?
A. “Do not wash your hair the morning of the procedure.”
B. “Try to stay awake most of the night prior to the procedure.”
C. “The procedure will take approximately 15 minutes.”
D. “You will need to lie flat for 4 hours after the procedure.”
Chapter 5 Meningitis
1. A nurse is assessing a client who reports severe headache and a stiff neck. The nurse’s assessment reveals positive Kernig’s and Brudzinski’s signs. Which of the following actions should the nurse perform
first?
A. Administer antibiotics.
B. Implement droplet precautions.
C. Initiate IV access.
D. Decrease bright lights.
2. A nurse is assessing for the presence of Brudzinski’s sign in a client who has suspected meningitis. Whichof the following actions should the nurse take when performing this technique? (Select all that apply.)
A. Place client in supine position.
B. Flex client’s hip and knee.
C. Place hands behind the client’s neck. D. Bend client’s head toward chest.
E. Straighten the client’s flexed leg at the knee.
3. A nurse is planning care for aclient who has meningitis and isat risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Implement seizure precautions.
B. Perform neurological checks four times a day.
C. Administer morphine for the report of neck and generalized pain.
D. Turn off room lights and television.
E. Monitor for impaired extraocular movements.
F. Encourage the client to cough frequently.
4. A nurse is reviewing the use of the meningococcal vaccine (MCV4)for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include?
A. The vaccine is indicated to reduce the risk of respiratory infection.
B. The vaccine is administered in a series of four doses.
C. The vaccine is recommended for adolescents before starting college.
D. The vaccine is initially given at 2 months of age.
5. A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
A. Monitor for bradycardia.
B. Provide an emesis basin at the bedside.
C. Administer antipyretic medication. D.Perform a skin assessment.
E. Keep the head of the bed flat.
Chapter 6 Seizures and Epilepsy
1. A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is aboutto have a seizure. Which of the following actions should the nurse implement? (Select all that apply.)
A. Provide privacy.
B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client’s clothing.
E. Protect the client’s head with padding.
F. Restrain the client.
2. A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?
A. Keep the client in a side‐lying position.
B. Document the duration of the seizure.
C. Reorient the client to the environment.
D. Provide client hygiene.
3. A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include?
A. Consider taking oral contraceptives when on this medication.
B. Watch for receding gums when taking the medication.
C. Take the medication at the same time every day.
D. Provide a urine sample to determine therapeutic levels of the medication.
4. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosisof generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.)
A. Avoid overwhelming fatigue.
B. Remove caffeinated products from the diet. C. Limit looking at flashing lights.
D. Perform aerobic exercise.
E. Limit episodes of hypoventilation.
F. Use of aerosol hairspray is recommended.
5. A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Whichof the following statements should the nurse include in the teaching?
A. “It is safe to use microwaves that are 1,200 watts or less.” .
B. “You should avoid the use of CT scans with contrast.”.
C. “You should place a magnet over the implantable device when you feelan aura occurring.”
D. “It is recommended that you use ultrasound diathermy for pain management.” Chapter 7 Parkinson’s Disease
1. A nurse is caring for a clientwho displays signs of stage III Parkinson’s disease. Which of the following actions should the nurse include in the plan of care?
A. Recommend a community support group.
B. Integrate a daily exercise routine.
C. Provide a walker forambulation.
D. Perform ADLs for the client.
2. A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson’s disease. Which actions should the nurse include in the plan of care? (Select all that apply.)
A. Provide three large balanced meals daily.
B. Record diet and fluid intake daily.
C. Document weight every other week.
D. Place the client in Fowler’s position to eat.
E. Offer nutritional supplements between meals / Offer cold fluids such as milkshakes
3. A nurse is reinforcing teaching with a client who has Parkinson’s disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching?
A. Rise slowly when standing.
B. Expect urine to become dark‐colored.
C. Avoid foods containing
D. Report any skin discoloration. [Show Less]