ATI Med Surge exam, 2022
(answered&graded)
A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral
aneurysm. If the client manifests increased intracranial pressure, which of the following findings
should the nurse expect?
(Select all that apply)
A. Violent headache
B. Neck pain and stiffness
C. Slurred speech
D. Projectile vomiting
E. Rapid loss of consciousness
C. Slurred speech
D. Projectile vomiting
E. Rapid loss of consciousness
A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an
appropriate finding by the nurse?
A. Severe headache
B. Bradycardia
C. Increased muscle tone
D. Oriented to time, person, place
A nurse admits a client who has a concussion for overnight observation. Alert and oriented on
admission, the client reports a headache along with neck pain and generalized muscle aches. The
nurse knows that a manifestation considered an early indication of increased intracranial pressure
(ICP) is:
A. bradycardia
B. ipsilateral pupil dilation.
C. widening pulse pressure.
D. lethargy.
,A nurse is caring for a client following a CVA and observes the client experiencing severe
dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely
be prescribed?
A. NPO until dysphagia subsides
B. Supplements via nasogastric tube
C. Initiation of total parenteral nutrition
D. Soft residue diet - B. Supplements via nasogastric tube
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse
how she should communicate with the client. Which of the following is an appropriate response by
the nurse?
A. "Incorporate nonverbal cues in the conversation."
B. "Ask multiple choice questions as part of the conversation."
C. "Use a higher-pitched tone of voice when speaking."
D. "Use simple child-like statements when speaking." - A. "Incorporate nonverbal cues in the
conversation."
A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is
prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client
must carefully be observed for which of the following complications?
A. Dehydration
B. Seizures
C. Burns
D. Shivering - D. Shivering
An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain
tumor. When performing a neurological examination, which of following is the most reliable
indicator of cerebral status?
A. Pupil response
B. Deep tendon reflexes
C. Muscle strength
D. Level of consciousness - D. Level of consciousness
, A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident
(CVA). Because the client's CVA affected the left side of the brain, which of the following goals
should the nurse anticipate including in the client's rehabilitation program?
A. Establish the ability to communicate effectively.
B. Have a regular, formed stool at least every other day.
C. Learn to control impulsive behavior
D. Improve left-side motor function. - A. Establish the ability to communicate effectively.
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck
there is an involuntary flexion of both legs. Which of the following conditions is the client
displaying?
A. Kernig's sign
B. Nuchal rigidity
C. Brudzinski sign
D. Bradykinesia - C. Brudzinski sign
A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the
following is the priority action by the nurse?
A. Administer antibiotics when available.
B. Reduce environmental stimuli.
C. Document intake and output.
D. Maintain seizure precautions. - A. Administer antibiotics when available.
A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following
interventions should the nurse implement to prevent foot-drop?
A. Place sandbags to maintain right plantar flexion.
B. Position soft pillows against the bottom of the feet.
C. Support the right foot in dorsiflexion with a footboard.
D. Splint the right lower extremity to maintain proper alignment. - C. Support the right foot in
dorsiflexion with a footboard.
A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of
the following should be addressed by an occupational therapist?
(answered&graded)
A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral
aneurysm. If the client manifests increased intracranial pressure, which of the following findings
should the nurse expect?
(Select all that apply)
A. Violent headache
B. Neck pain and stiffness
C. Slurred speech
D. Projectile vomiting
E. Rapid loss of consciousness
C. Slurred speech
D. Projectile vomiting
E. Rapid loss of consciousness
A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an
appropriate finding by the nurse?
A. Severe headache
B. Bradycardia
C. Increased muscle tone
D. Oriented to time, person, place
A nurse admits a client who has a concussion for overnight observation. Alert and oriented on
admission, the client reports a headache along with neck pain and generalized muscle aches. The
nurse knows that a manifestation considered an early indication of increased intracranial pressure
(ICP) is:
A. bradycardia
B. ipsilateral pupil dilation.
C. widening pulse pressure.
D. lethargy.
,A nurse is caring for a client following a CVA and observes the client experiencing severe
dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely
be prescribed?
A. NPO until dysphagia subsides
B. Supplements via nasogastric tube
C. Initiation of total parenteral nutrition
D. Soft residue diet - B. Supplements via nasogastric tube
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse
how she should communicate with the client. Which of the following is an appropriate response by
the nurse?
A. "Incorporate nonverbal cues in the conversation."
B. "Ask multiple choice questions as part of the conversation."
C. "Use a higher-pitched tone of voice when speaking."
D. "Use simple child-like statements when speaking." - A. "Incorporate nonverbal cues in the
conversation."
A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is
prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client
must carefully be observed for which of the following complications?
A. Dehydration
B. Seizures
C. Burns
D. Shivering - D. Shivering
An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain
tumor. When performing a neurological examination, which of following is the most reliable
indicator of cerebral status?
A. Pupil response
B. Deep tendon reflexes
C. Muscle strength
D. Level of consciousness - D. Level of consciousness
, A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident
(CVA). Because the client's CVA affected the left side of the brain, which of the following goals
should the nurse anticipate including in the client's rehabilitation program?
A. Establish the ability to communicate effectively.
B. Have a regular, formed stool at least every other day.
C. Learn to control impulsive behavior
D. Improve left-side motor function. - A. Establish the ability to communicate effectively.
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck
there is an involuntary flexion of both legs. Which of the following conditions is the client
displaying?
A. Kernig's sign
B. Nuchal rigidity
C. Brudzinski sign
D. Bradykinesia - C. Brudzinski sign
A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the
following is the priority action by the nurse?
A. Administer antibiotics when available.
B. Reduce environmental stimuli.
C. Document intake and output.
D. Maintain seizure precautions. - A. Administer antibiotics when available.
A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following
interventions should the nurse implement to prevent foot-drop?
A. Place sandbags to maintain right plantar flexion.
B. Position soft pillows against the bottom of the feet.
C. Support the right foot in dorsiflexion with a footboard.
D. Splint the right lower extremity to maintain proper alignment. - C. Support the right foot in
dorsiflexion with a footboard.
A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of
the following should be addressed by an occupational therapist?
