Adult Health ATI questions & answers
A nurse is caring for a client who is 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 - ANSWER-b. assist the client to a
supine position
c. administer an opioid medication
d. encourage the client to increase fluid intake
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular
catheter 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 - ANSWER-b. infection
A nurse is assessing a client for changes in the level of consciousness using the Glasgow coma scale. 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 - ANSWER-b. E3 + V4 + M4 = 11
,A nurse is developing a plan of care for a client who 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" - ANSWER-a. "I think I might be pregnant"
b. "I take warfarin"
d. "I am allergic to shrimp"
e. "I ate a light breakfast this morning"
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." - ANSWER-b. "Try to stay awake most of the
night prior to the procedure."
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a
seizure. Which of the following actions should the nurse implement?
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 - ANSWER-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
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 - ANSWER-a. keep the client in a side-lying position
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 - ANSWER-c. take the
medication at the same time every day
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of
generalized seizures. Which of the following information should the nurse include in the 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 - ANSWER-a. avoid overwhelming fatigue
b. remove caffeinated products from the diet
c. limit looking at flashing lights
, A nurse is completing discharge teaching to a client who has seizures and receiving a vagal nerve
stimulator to decrease seizure activity. Which of 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 feel an aura occurring."
d. "It is recommended that you use ultrasound diathermy for pain management." - ANSWER-c. "You
should place a magnet over the implantable device when you feel an aura occurring."
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse
expect?
a. fluctuations in blood pressure
b. loss of cognitive function
c. ineffective cough
d. drooping eye lids - ANSWER-b. loss of cognitive function
A nurse is beginning a physical assessment of a client who has anew diagnosis of multiple sclerosis.
Which of the following findings should the nurse expect? (select all that apply)
a. areas of paresthesia
b. involuntary eye movements
c. alopecia
d. increased salivation
e. ataxia - ANSWER-a. areas of paresthesia
b. involuntary eye movements
e. ataxia
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the
following statements should the nurse include in the teaching?
a. "this medication will help you with your tremors"
b. "this medication will help you with your bladder function"
c. "this medication may cause your skin to bruise easily"
A nurse is caring for a client who is 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 - ANSWER-b. assist the client to a
supine position
c. administer an opioid medication
d. encourage the client to increase fluid intake
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular
catheter 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 - ANSWER-b. infection
A nurse is assessing a client for changes in the level of consciousness using the Glasgow coma scale. 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 - ANSWER-b. E3 + V4 + M4 = 11
,A nurse is developing a plan of care for a client who 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" - ANSWER-a. "I think I might be pregnant"
b. "I take warfarin"
d. "I am allergic to shrimp"
e. "I ate a light breakfast this morning"
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." - ANSWER-b. "Try to stay awake most of the
night prior to the procedure."
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a
seizure. Which of the following actions should the nurse implement?
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 - ANSWER-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
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 - ANSWER-a. keep the client in a side-lying position
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 - ANSWER-c. take the
medication at the same time every day
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of
generalized seizures. Which of the following information should the nurse include in the 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 - ANSWER-a. avoid overwhelming fatigue
b. remove caffeinated products from the diet
c. limit looking at flashing lights
, A nurse is completing discharge teaching to a client who has seizures and receiving a vagal nerve
stimulator to decrease seizure activity. Which of 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 feel an aura occurring."
d. "It is recommended that you use ultrasound diathermy for pain management." - ANSWER-c. "You
should place a magnet over the implantable device when you feel an aura occurring."
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse
expect?
a. fluctuations in blood pressure
b. loss of cognitive function
c. ineffective cough
d. drooping eye lids - ANSWER-b. loss of cognitive function
A nurse is beginning a physical assessment of a client who has anew diagnosis of multiple sclerosis.
Which of the following findings should the nurse expect? (select all that apply)
a. areas of paresthesia
b. involuntary eye movements
c. alopecia
d. increased salivation
e. ataxia - ANSWER-a. areas of paresthesia
b. involuntary eye movements
e. ataxia
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the
following statements should the nurse include in the teaching?
a. "this medication will help you with your tremors"
b. "this medication will help you with your bladder function"
c. "this medication may cause your skin to bruise easily"
