ATI Quiz WK 6 Nur 242 with complete solutions 2024_2025.
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Course
Nur242
Institution
Nur242
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
-Teach controlled coughing and deep breathing.
-Provide a brightly lit environment.
-Elevate the head of the bed 20°.
-Encourage a minimum intake of 2000 ...
ATI Quiz WK 6 Nur 242 with complete
solutions 2024/2025
A nurse is caring for a client who has increased intracranial pressure. Which of
the following interventions should the nurse take?
-Teach controlled coughing and deep breathing.
-Provide a brightly lit environment.
-Elevate the head of the bed 20°.
-Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.
Elevate the head of the bed 20°.
The nurse should elevate the head of the bed less than 25° to promote reduction
of intracranial pressure.
A nurse is receiving a transfer report for a client who has a head injury. The client
has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal
response, and 5 for best motor response. Which of the following is an appropriate
conclusion based on this data?
-The client can follow simple motor commands.
-The client is unable to make vocal sound.
-The client is unconscious.
-The client opens his eyes when spoken to.
The client opens his eyes when spoken to.
A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is
oriented, and is able to localize pain.
A nurse is planning care for a client who states he is anxious concerning
abdominal surgery. Which of the following actions should the nurse take?
-Explain to the client that all patients feel that way prior to surgery.
-Suggest the client talk to the provider.
-Ask the client what to expect tomorrow.
-Encourage the client to express negative emotions.
Encourage the client to express negative emotions.
,The nurse is acknowledging the client's negative emotions, therefore providing
open therapeutic communication.
A nurse in the emergency department is caring for a client who has myasthenia
gravis and is in crisis. Which of the following factors should the nurse identify as
a possible cause of myasthenic crisis?
-Developing a respiratory infection
-Taking too much prescribed medication
-Diet high in protein
-Not exercising enough
Developing a respiratory infection
The most common triggers of myasthenic crises are respiratory infection, not
taking, or taking too little, of the prescribed medication, surgery, and high
environmental temperatures.
A nurse is providing postoperative teaching to a client who is scheduled for
cataract surgery. Which of the following information should the nurse include?
-"Bloodshot eyes on the day of surgery should be reported to
the provider."
-"Warm compresses should be applied to the eye three times daily."
-"Photophobia is expected for 2 to 3 days."
-"Vision will be greatly improved on the day of surgery."
"Vision will be greatly improved on the day of surgery."
Vision should be greatly improved on the day of surgery. This information should
be included in the teaching.
A nurse is assessing the reflexes of a client who has an unrepaired femur fracture
and has suddenly become stuporous. For which of the following findings should
the nurse identify that the client exhibits Babinski's sign?
-Pinpoint pupils
-Jerking contractions of the head and neck
-Pronation of the arms
-Dorsiflexion of the great toe
Dorsiflexion of the great toe
Dorsiflexion of the great toe and fanning of the other toes when the plantar reflex
is assessed is an indication of a Babinski's sign, an abnormal response that
indicates CNS pathology.
A nurse is preparing to administer an osmotic diuretic IV to a client with
increased intracranial pressure. Which of the following should the nurse identify
as the purpose of the medication?
, -Reduce edema of the brain.
-Provide fluid hydration.
-Increase cell size in the brain.
-Expand extracellular fluid volume.
Reduce edema of the brain.
An osmotic diuretic is used to decrease intracranial pressure by moving fluid out
of the ventricles into the bloodstream.
A nurse is shopping and finds a woman who has collapsed with right-sided
weakness and slurred speech. Which of the following action should the nurse
take?
-Provide the client with water to test the gag reflex.
-Perform carotid massage.
-Notify emergency management services.
-Drive the client to the nearest medical facility.
Notify emergency management services.
The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to
administering appropriate treatment; therefore, the nurse should call the
emergency management services.
A nurse is assessing a client who has meningitis. Which of the following findings
should the nurse expect?
-Severe headache
-Bradycardia
-Blurred vision
-Oriented to person, place, and year
Severe headache
The nurse should expect a client who has meningitis to manifest a severe
headache due to meningeal inflammation.
A nurse is caring for a client who is unconscious following a cerebral
hemorrhage. Which of the following nursing interventions is of highest priority?
-Perform passive range of motion on each extremity.
-Monitor the client's electrolyte levels.
-Suction saliva from the client's mouth.
-Record the client's intake and output.
Suction saliva from the client's mouth.
The unconscious client is unable to independently maintain a clear airway and is
at risk for ineffective airway clearance. According to the safety and risk reduction
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