Adult Health ATI questions
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"
d. "this medication may cause you to experience weakness" - answer-d. "this medication may
cause you to experience weakness"
A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks
about foods that can cause headaches. The should recommend that the client avoid which of
the following foods?
a. baked salmon
b. salted cashews
c. frozen strawberries
d. fresh asparagus - answer-b. salted cashews
A nurse in a clinic is teaching a client who has a history of migraine headaches about a new
prescription for zolmitriptan. Which of the following statements by the client indicates
understanding of the teaching?
a. "this medication will relieve my symptoms by causing my blood vessels to dilate"
b. "I should take this medication daily to prevent the headache from occurring"
c. "I should except facial flushing when I take this medication"
d. "this medication will lower my sensitivity to food triggers" - answer-c. "I should except facial
flushing when I take this medication"
A nurse in a provider's office is obtaining a health history form a client who has cluster
headaches. Which of the following are expected findings? (select all that apply)
a. pain is bilateral across the posterior occipital area
b. client experiences altered sleep-wake cycle
c. headache occurs at approximately at the same time of the day
d. client describes headache pain as dull and throbbing
e. nasal congestion and drainage occur - answer-b. client experiences altered sleep-wake cycle
c. headache occurs at approximately at the same time of the day
, e. nasal congestion and drainage occur
A nurse is providing discharge instruction to a client who has a new diagnosis of migraine
headaches. Which of the following instructions should the nurse include?
a. use music therapy for relaxation with the onset of the headache
b. increase physical activity when a headache is present
c. drink beverages that contain artificial sweeteners to prevent headaches
d. apply a cool cloth to the face during a headache - answer-d. apply a cool cloth to the face
during a headache
A nurse is obtaining a health history from a client who is being evaluated for the cause of
frequent headaches. Which of the following questions should the nurse ask to identify the
findings of migraine headaches?
a. "do the headaches occur at the same time each day?"
b. "is your headache accompanied by profuse facial sweating?"
c. "does your headache occur on one of your head?"
d. "is there a pattern of headaches among family members?" - answer-d. "is there a pattern of
headaches among family members?"
A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of
peripheral vision. The nurse should recognize this as a manifestation of which of the following
diseases?
a. cataracts
b. open-angle glaucoma
c. macular degeneration
d. angle-closure glaucoma - answer-b. open-angle glaucoma
A nurse is providing postoperative teaching to a client following cataract surgery. Which of the
following statements should the nurse include in the teaching?
a. "you can resume playing golf in 2 days"
b. "you need to tilt you head back when washing your hair"
c. "you can get water in your eyes in 1 day"
d. "you need to limit your housekeeping activities" - answer-d. "you need to limit your
housekeeping activities"
A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of
the following should the nurse recognize as risk factors associated with this disease? (select all
that apply)
a. gender
b. genetic predisposition
c. hypertension
d. age
e. diabetes mellitus - answer-b. genetic predisposition
c. hypertension
d. age
e. diabetes mellitus
A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following
manifestations should the nurse expect? (select all that apply)
a. eye pain
b. floating spots
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"
d. "this medication may cause you to experience weakness" - answer-d. "this medication may
cause you to experience weakness"
A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks
about foods that can cause headaches. The should recommend that the client avoid which of
the following foods?
a. baked salmon
b. salted cashews
c. frozen strawberries
d. fresh asparagus - answer-b. salted cashews
A nurse in a clinic is teaching a client who has a history of migraine headaches about a new
prescription for zolmitriptan. Which of the following statements by the client indicates
understanding of the teaching?
a. "this medication will relieve my symptoms by causing my blood vessels to dilate"
b. "I should take this medication daily to prevent the headache from occurring"
c. "I should except facial flushing when I take this medication"
d. "this medication will lower my sensitivity to food triggers" - answer-c. "I should except facial
flushing when I take this medication"
A nurse in a provider's office is obtaining a health history form a client who has cluster
headaches. Which of the following are expected findings? (select all that apply)
a. pain is bilateral across the posterior occipital area
b. client experiences altered sleep-wake cycle
c. headache occurs at approximately at the same time of the day
d. client describes headache pain as dull and throbbing
e. nasal congestion and drainage occur - answer-b. client experiences altered sleep-wake cycle
c. headache occurs at approximately at the same time of the day
, e. nasal congestion and drainage occur
A nurse is providing discharge instruction to a client who has a new diagnosis of migraine
headaches. Which of the following instructions should the nurse include?
a. use music therapy for relaxation with the onset of the headache
b. increase physical activity when a headache is present
c. drink beverages that contain artificial sweeteners to prevent headaches
d. apply a cool cloth to the face during a headache - answer-d. apply a cool cloth to the face
during a headache
A nurse is obtaining a health history from a client who is being evaluated for the cause of
frequent headaches. Which of the following questions should the nurse ask to identify the
findings of migraine headaches?
a. "do the headaches occur at the same time each day?"
b. "is your headache accompanied by profuse facial sweating?"
c. "does your headache occur on one of your head?"
d. "is there a pattern of headaches among family members?" - answer-d. "is there a pattern of
headaches among family members?"
A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of
peripheral vision. The nurse should recognize this as a manifestation of which of the following
diseases?
a. cataracts
b. open-angle glaucoma
c. macular degeneration
d. angle-closure glaucoma - answer-b. open-angle glaucoma
A nurse is providing postoperative teaching to a client following cataract surgery. Which of the
following statements should the nurse include in the teaching?
a. "you can resume playing golf in 2 days"
b. "you need to tilt you head back when washing your hair"
c. "you can get water in your eyes in 1 day"
d. "you need to limit your housekeeping activities" - answer-d. "you need to limit your
housekeeping activities"
A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of
the following should the nurse recognize as risk factors associated with this disease? (select all
that apply)
a. gender
b. genetic predisposition
c. hypertension
d. age
e. diabetes mellitus - answer-b. genetic predisposition
c. hypertension
d. age
e. diabetes mellitus
A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following
manifestations should the nurse expect? (select all that apply)
a. eye pain
b. floating spots
