ATI Targeted Medical Surgical Neurosensory and Musculoskeletal questions with answers,

ATI Targeted Medical Surgical Neurosensory
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and Musculoskeletal questions with answers
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A nurse is planning care for a client who has a closed traumatic brain injury
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from a fall and is receiving mechanical ventilation. Which of the following
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intervention is the nurse's priority? |\ |\ |\ |\




A. Maintain a PaCO2 of approx. 35 mmHg
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B. Provide small doses of fentanyl via bolus for pain management
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C. Measure body temperature every 1-2hr - CORRECT ANSWERS ✔✔A.
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Maintain a PaCO2 of approx. 35 mmHg |\ |\ |\ |\ |\ |\




The greatest risk to this client is injury from increased intracranial pressure.
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Therefore, the nurse's priority action is to maintain the PaCO2 at
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approximately 35 mm Hg to prevent hypercarbia and subsequent |\ |\ |\ |\ |\ |\ |\ |\ |\



vasodilation effects that lead to increase in intracranial pressure.
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A nurse is caring for a client who has a retinal detachment. which of the
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following findings should the nurse expect?
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A. Photophobia
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B. Complete vision loss
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C. Flashes of bright light
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D. Cloudiness of the lends - CORRECT ANSWERS ✔✔C. Flashes of bright
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light

,The nurse should expect a client who has a retinal detachment to see flashes
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of bright light or floating dark spots in the affected eye as the retinal layers
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separate.

Photophobia - The nurse should expect photophobia in a client who has a
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migraine headache. |\




Complete vision loss |\ |\




-The nurse should expect a client who has a retinal detachment to have
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some visual field loss in the area of the detachment, but complete vision loss
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is not an expected finding.
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Cloudiness of the lens- The nurse should expect a client who has cataracts to
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experience cloudiness of the lens
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A nurse is caring for a client who has a spastic bladder following a spinal
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cord injury. Which of the following actions should the nurse take to help
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stimulate micturition? |\




A. Encourage the client to use the Valvalsa maneuver
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B. Stroke the client's inner thigh
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C. Perform the Crede maneuver
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D. Administer a diuretic - CORRECT ANSWERS ✔✔B. Stroke the client's
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inner thigh |\




The nurse should stimulate micturition by stroking the client's inner thigh.
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Other techniques include pinching the skin above the groin and providing
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digital anal stimulation. |\ |\

, Perform the Credé maneuver.The nurse should apply direct pressure over the
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client's bladder, also known as the Credé maneuver, to express urine from a
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flaccid bladder. It is not effective for clients who have a spastic bladder due
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to the spasticity of the external sphincter.
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Administer a diuretic.Antispasmodics such as oxybutynin, rather than |\ |\ |\ |\ |\ |\ |\ |\



diuretics, can be effective for treating mild spastic bladder problems.
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Encourage the client to use the Valsalva maneuver.-The nurse should
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encourage the client to hold their breath and bear down, also known as the
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Valsalva maneuver, to express urine from a flaccid bladder. It is not effective
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for clients who have a spastic bladder due to the spasticity of the external
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sphincter.



A nurse is caring for a client who has viral meningitis. Which of the
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following actions should the nurse take? |\ |\ |\ |\ |\




A. Assess the client's neurologic status every 8 hr
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B. Initiate droplet precautions
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C. Check capillary refill at least every 4 hr
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D. Place the client in a well-lit environment - CORRECT ANSWERS ✔✔C.
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Check capillary refill at least every 4hr-The nurse should perform a complete
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vascular assessment at least every 4 hr to monitor for vascular compromise
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Place the client in a well-lit environment.
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The nurse should minimize the client's exposure to light from windows and
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overhead lights because photophobia, or light sensitivity, is a manifestation
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of viral meningitis.
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