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ATI NEUROSENSORY ( UPDATED 2024 ) COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
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ATI NEUROSENSORY ( UPDATED 2024 ) COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
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ATI NEUROSENSORY ( UPDATED 2024 )COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
1. client sustained multiple injuries related to motor vehicle crash. When monitoring for
manifestations of pneumothorax, what should nurse observefor ?: absence of breath sounds
(will have diminished/absent breath sounds on affected side due to partial/total collapse of
lung)
2. client has a cerebral aneurysm. What finding should nurse report ?: client asks that his bed
linens be changed after an episode of urinary incontinence (urinary incontinence indicates a loss
of reflex function, indicating ICP)
3. caring for client who sustained a basal skull fracture. Notices a thin streamof clear drainage
coming from right nostril. Priority nursing action ?: test thedrainage for glucose (because of
high risk of cerebral spinal fluid leak w/ basal skullfractures)
4. collecting data for a neurological assessment for a client receiving tx for head trauma.
What info is needed for function of the 3rd cranial nerve ?: instructthe client to look up & down
without moving his head (extraocular eye movements)
5. monitoring spinal cord injury & suspects autonomic dysreflexia. Whataction should be
implemented 1st ?: place the client in a sitting position (to decrease the symptom of
hypertension for autonomic dysreflexia)
6. client had a craniotomy 3 weeks ago & remains unconscious. While bathing client, the AP
talk to him about current events. Clients wife asks aboutAP's actions. What statement reinforces
clients wife the importance of talkingto client ?: "Clients like your husband, who are
unconscious, may still be able to her." (provides sensory stimulation & should be encouraged)
7. a family member is instructed on interventions for safe swallowing for client who has
residual effects from a stroke. Whats most important conceptfor family members to
understand ?: place the client in the upright position to facilitate swallowing (greatest risk for
client is injury from aspiration)
8. nurse is caring for client w/ a spinal cord injury at T-4. Nurse understands that client is at
increased risk for autonomic dysreflexia & that this physiologic reaction could be triggered by
what ?: bladder distention (autonomic dysreflexia can occur w/ spinal cord injury at/above T-6
level. A. dysreflexia happens when theres irritation, pain, or stimulus to nervous system below
level of injury. Most are relatedto bladder, bowel, & skin)
9. client is about to start using transcutaneous electrical nerve stimulation (TENS) to
manage chronic pain. Whats a statement indicating need for teaching ?: "It's unfortunate that I
have to be in the hospital for this tx." (client must attachelectrode pads to skin of choice &
should remove hair for pads)
, 10. client is a quadriplegic from a spinal cord injury & is adjusting to home environment. What
client statement indicates adapting ?: "I am using the modified feeding utensils at every meal. I
still spill, but I'm getting better."
11. preparing a presentation about various herbal remedies. What herbal supp might be used to
help boost their memory ?: Ginkgo biloba (Valerian: sedation & anxiety relief for sleep issues;
Goldenseal: antiseptic properties, especially w/ topicalapp; St. John's wort: depression)
12. conducting a Parkinson's disease group for family. What should nurse reinforce in the
teaching ?: provide client supervision (to create a safe & respectfulenvironment. Provide exercise
program to improve mobility, alternate w/ rest periods.Should also decrease excess
environmental noise to increase clients ability to concentrate on listening)
13. implementing a plan of care for client w/ a cerebral aneurysm.What nursingmeasures should
be implemented ?: encourage exhaling through mouth when defecating (to decrease strain
possible rupture of the aneurysm)
14. ED nurse is assisting care of a client who has myasthenia gravis & is
in crisis. What factors can cause myasthenic crisis ?: developing a respiratory
infection (most common triggers: resp infection, not taking or taking too little of meds,surgery, &
pregnancy)
15. client has a severe head injury. What finding indicates development diabetes insipidus
(DI) ?: urine output 250 ml/hr (the resulting decrease in antidiuretichormone results in an
increasingly high output of very dilute urine)
16. modifying the diet of a client who has Parkinson's disease that's pre- scribed a monamine
oxidase inhibitor (MAOI). What foods should be eliminated ?: cheese (it contains tyramine
which may cause hypertensive crisis)
17. caring for client who has an intracranial aneurysm & requires precautions.Whats an
appropriate nursing intervention ?: minimize environmental stimuli (atrisk for rupture &
should avoid any stimulation that could cause anxiety, such as noise or bright lights; raise hob
15-30°; remain on bed rest)
18. caring for client at risk for increased intracranial pressure, monitors forindications that
pressure is increasing. Nurse should check function of the3rd cranial nerve by...: checking
pupillary response to light (cranial nerve III, oculomotor nerve, is responsible for pupillary
response to light)
19. caring for client who has progressive presbycusis. Whats an appropriatenursing action ?:
speak directly to the client in a normal, clear voice
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