NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
A nurse is collecting data from a client following a recent head injury. What finding should
the nurse recognize as a manifestation of increased intracranial pressure?
Widened pulse pressure - This is the diff btwn the systolic & diastolic which is a s/s of
increased ICP. Other manifestations include pupil changes, changes in LOC, and N/V.
Tachycardia can be a s/s of hypovolemia but bradycardia is a s/s of ICP.
Periorbital Edema - Can occur after eye trauma or craniotomy, but it
is not a s/s of ICP. Decrease in Urine Output - Can be a s/s of
hypovolemia but is not a s/s of ICP.
A nurse is caring for a client who has closed head injury. The nurse should place the client in
which position?
Semi-flowers - This position prevents an increase in ICP. It permits bld flow to the pts brain
while allowing venous drainage, thereby decrease in the postoperative risk of ICP.
Prone position is lying flat on abdomen, this increases ICP.
Trendelenburg can increase the ICP thus this position is contraindicated following a craniotomy.
Sim’s position is a side lying w/ flexion of hips and knee. Flexing hip or neck can cause increase
in ICP.
A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease
(AD). Which of the following information should the nurse include in the teaching?
Limit choices offered to the client.
Rationale: Choices should be limited for the client who has stage II AD to reduce confusion and
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
,NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
frustration.
Pt w/ stage II AD can become fearful of pictures of people or objects. The pts rom should
not have pictures on the wall that can confuse or scare the pt.
Noise can increase anxiety in a pt who has stage II AD. The pt’s environment should be quiet
to reduce stress and promote rest.
Pt w/ stage II AD can become agitated from reality orientation. Validation therapy can show
acceptance of the pt’s feelings.
A nurse is providing discharge teaching to a client who is postoperative following scleral
buckling to repair a detached retina. Which of the following instructions should the nurse
include in the teaching?
You should avoid reading for 1 week.
Rationale: The client should avoid reading and any activity that can cause rapid movement of
the eye because of the risk for detachment of the retina.
The pts vision will not be restored immediately after procedure b/c of swelling of the eye and
the dilating effects of eye drops. Pt’s vision should return gradually over several seeks.
Pt should wear eye shields for 2-6 wks after surgery when sleeping to protect the eye form
injury. The pt should not lift objects that weigh more than 20 lbs to prevent an increase in
intraocular pressure.
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
,NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
A nurse is providing teaching to the family of a client who has a new diagnosis of
amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of
the following findings is an early manifestations of ALS?
Weakness of the distal extremities
Rationale: ALS is a progressive neurodegenerative disease that involves the motor nerve cells
in the brain and the spinal cord causing muscle wasting, spasticity, and eventually paralysis.
Early manifestations of ALS include increasing muscle weakness, especially involving the
distal arms and legs (hands and feet), speech, swallowing, and breathing.
ALS does NOT cause visual changes, does not affect the autonomic NS, the sensory NS, or temp
regulation.
ALS is a progressive neurodegenerative disease that affects the motor nerve cells int eh brain
and the spinal cord.
A nurse is providing teaching to the partner of a client who has a new diagnosis of
Parkinson's disease about degenerative complications. The nurse should include in the
teaching that which of the following manifestations is the priority?
Dysphagia - Can lead to aspiration.
Emotional Liability - This & depression are assoc. w/ Parkinson’s but it
is not the priority. Impaired Speech - This is assoc. w/ Parkinson’s but
not the priority.
Self-Care Dependency -Occurrence of self care dependency is assoc. w/ Parkinson’s but not the
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
, NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
priority.
The nurse should apply the ABC priority-setting framework. This framework emphasizes the
basic core of human functioning, which is having an open airway, being able to breathe in
adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An
alteration in any of these can indicate a threat to life and should be the nurse's priority
concern.
When applying the ABC priority-setting framework, the airway is the nurse's priority concern.
When applying the ABC priority- setting framework, the airway is the priority because it must
be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC
priority-setting framework because adequate ventilatory effort is essential for oxygen exchange
to occur. Circulation is the third priority in the ABC priority-setting framework because delivery
of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently
carrying oxygen to them. Therefore, dysphagia is the priority manifestation because it can lead
to aspiration.
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG).
Which of the following information should the nurse include in the teaching? (Select all that
apply.)
Driving can be dangerous due to loss of peripheral vision - Damage to the optic nerve that
occurs secondary to ICP causes a decrease in peripheral vision and can cause complete vision
loss if not treated.
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
A nurse is collecting data from a client following a recent head injury. What finding should
the nurse recognize as a manifestation of increased intracranial pressure?
Widened pulse pressure - This is the diff btwn the systolic & diastolic which is a s/s of
increased ICP. Other manifestations include pupil changes, changes in LOC, and N/V.
Tachycardia can be a s/s of hypovolemia but bradycardia is a s/s of ICP.
Periorbital Edema - Can occur after eye trauma or craniotomy, but it
is not a s/s of ICP. Decrease in Urine Output - Can be a s/s of
hypovolemia but is not a s/s of ICP.
A nurse is caring for a client who has closed head injury. The nurse should place the client in
which position?
Semi-flowers - This position prevents an increase in ICP. It permits bld flow to the pts brain
while allowing venous drainage, thereby decrease in the postoperative risk of ICP.
Prone position is lying flat on abdomen, this increases ICP.
Trendelenburg can increase the ICP thus this position is contraindicated following a craniotomy.
Sim’s position is a side lying w/ flexion of hips and knee. Flexing hip or neck can cause increase
in ICP.
A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease
(AD). Which of the following information should the nurse include in the teaching?
Limit choices offered to the client.
Rationale: Choices should be limited for the client who has stage II AD to reduce confusion and
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
,NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
frustration.
Pt w/ stage II AD can become fearful of pictures of people or objects. The pts rom should
not have pictures on the wall that can confuse or scare the pt.
Noise can increase anxiety in a pt who has stage II AD. The pt’s environment should be quiet
to reduce stress and promote rest.
Pt w/ stage II AD can become agitated from reality orientation. Validation therapy can show
acceptance of the pt’s feelings.
A nurse is providing discharge teaching to a client who is postoperative following scleral
buckling to repair a detached retina. Which of the following instructions should the nurse
include in the teaching?
You should avoid reading for 1 week.
Rationale: The client should avoid reading and any activity that can cause rapid movement of
the eye because of the risk for detachment of the retina.
The pts vision will not be restored immediately after procedure b/c of swelling of the eye and
the dilating effects of eye drops. Pt’s vision should return gradually over several seeks.
Pt should wear eye shields for 2-6 wks after surgery when sleeping to protect the eye form
injury. The pt should not lift objects that weigh more than 20 lbs to prevent an increase in
intraocular pressure.
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
,NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
A nurse is providing teaching to the family of a client who has a new diagnosis of
amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of
the following findings is an early manifestations of ALS?
Weakness of the distal extremities
Rationale: ALS is a progressive neurodegenerative disease that involves the motor nerve cells
in the brain and the spinal cord causing muscle wasting, spasticity, and eventually paralysis.
Early manifestations of ALS include increasing muscle weakness, especially involving the
distal arms and legs (hands and feet), speech, swallowing, and breathing.
ALS does NOT cause visual changes, does not affect the autonomic NS, the sensory NS, or temp
regulation.
ALS is a progressive neurodegenerative disease that affects the motor nerve cells int eh brain
and the spinal cord.
A nurse is providing teaching to the partner of a client who has a new diagnosis of
Parkinson's disease about degenerative complications. The nurse should include in the
teaching that which of the following manifestations is the priority?
Dysphagia - Can lead to aspiration.
Emotional Liability - This & depression are assoc. w/ Parkinson’s but it
is not the priority. Impaired Speech - This is assoc. w/ Parkinson’s but
not the priority.
Self-Care Dependency -Occurrence of self care dependency is assoc. w/ Parkinson’s but not the
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
, NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
priority.
The nurse should apply the ABC priority-setting framework. This framework emphasizes the
basic core of human functioning, which is having an open airway, being able to breathe in
adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An
alteration in any of these can indicate a threat to life and should be the nurse's priority
concern.
When applying the ABC priority-setting framework, the airway is the nurse's priority concern.
When applying the ABC priority- setting framework, the airway is the priority because it must
be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC
priority-setting framework because adequate ventilatory effort is essential for oxygen exchange
to occur. Circulation is the third priority in the ABC priority-setting framework because delivery
of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently
carrying oxygen to them. Therefore, dysphagia is the priority manifestation because it can lead
to aspiration.
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG).
Which of the following information should the nurse include in the teaching? (Select all that
apply.)
Driving can be dangerous due to loss of peripheral vision - Damage to the optic nerve that
occurs secondary to ICP causes a decrease in peripheral vision and can cause complete vision
loss if not treated.
NURSING NUR 305 ATI Medical/Surgical Neurosensory AH1
Exam Questions And Answers Graded A+ Assured Success
New Update 2022/2023 with rationales
