A nurse is caring for a client who is postprocedure following a 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 ...
ATI EXIT EXAM MED SURG II Questions
& Answers
A nurse is caring for a client who is postprocedure following a 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. - ANSWERSB.
Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
Rationale: (B) The nurse should assist the client to a supine position, which can relieve
a headache following a lumbar puncture
(C) The nurse should administer an opioid medication for a client's report of headache
pain. (D) The nurse should encourage increased fluid intake to maintain a positive fluid
balance, which can relieve a headache following a lumbar puncture
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) 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 - ANSWERSB. Infection
Rationale: The nurse should monitor a client who has a ventriculostomy for infection,
which is a complication. The nurse should use strict asepsis to avoid this life-threatening
condition, which can result in meningitis.
A nurse is assessing a client for changes in the level of consciousness using the
Glasgow Coma Scale (GCS). 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
Rationale: The client's score is calculated correctly, indicating moderate head injury. E3
represents opening eyes secondary to voice stimulation, V4 represents the verbal
conversation that is incoherent and disoriented and M4 represents motor response as
general withdrawal to pain.
A nurse is developing a plan of care for a client who is 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." - ANSWERSA. "I think I might be pregnant."
B. "I take warfarin."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning."
Rationale: (A) The nurse should report the client's statement of possible pregnancy to
the provider because the contrast dye can place the fetus at risk. (B) The nurse should
report that the client is taking warfarin to the provider due to the potential for bleeding
following angiography (D) The nurse should report a clients report of allergy to shrimp,
which is a shellfish, to the provider due to a potential allergic reaction to the contrast dye
(E) The nurse should report a client's intake of food to the provider since the client
should remain NPO for 4 to 6 hr. prior to the procedure.
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 away 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." - ANSWERSB. "Try to stay
away most of the night prior to the procedure."
Rationale: The nurse should teach the client to remain awake most of the night to
provide cranial stress and increase the possibility of abnormal electrical activity.
A nurse is assessing the pain level of a client who came to the emergency department
reporting severe abdominal pain. The nurse asks the client whether he has nausea and
has been vomiting. The nurse is assessing which of the following components of a pain
assessment?
,A. Presence of associated manifestations.
B. Location of the pain
C. Pain quality
D. Aggravating and relieving factors - ANSWERSA. Presence of associated
manifestations.
Rationale: Nausea and vomiting are common manifestations clients have when they are
in pain
A nurse is assessing a client who is reporting pain despite analgesia. Which of the
following actions should the nurse take to assess the intensity of the client's pain?
A. Ask the client what precipitates his pain.
B. Question the client about the location of his pain.
C. Offer the client a pain scale to measure his pain
D. Use open-ended questions to identify the sensation of his pain. - ANSWERSC. Offer
the client a pain scale to measure his pain
Rationale: The nurse should use a pain scale to help the client measure the amount of
pain he has and its intensity.
A nurse is caring for a client who is receiving morphine via a patient-controlled
analgesia (PCA) infusion device after abdominal surgery. Which of the following client
statements indicates that the client understands how to use the device?
A. "I'll wait to use the device until it's absolutely necessary."
B. "I'll be careful about pushing the button to I don't get an overdose."
C. "I should tell the nurse if the pain doesn't stop after I use this device."
D. "I will ask my son to push the dose button when I am sleeping." - ANSWERSC. "I
should tell the nurse if the pain doesn't stop after I use this device."
Rationale: The nurse should identify that PCA is a method of delivering pain medication
through an electronic infusion device that allows the client to self-administer pain
medication on an as-needed basis. If the client is not achieving adequate pain control,
he should let the nurse know so that she can initiate a reevaluation of the client's pain
management plan.
A nurse is discussing pain assessment with a newly licensed nurse. Which of the
following information should the nurse include?
A. Most clients exaggerate their level of pain.
B. Pain must have an identifiable source to justify the use of opioids.
C. Objective data are essential in assessing pain.
D. Pain is whatever the client says it is. - ANSWERSD. Pain is whatever the client says
it is.
, Rationale: The nurse should identify that pain is a subjective experience, and the client
is the best source of information about it.
A nurse is monitoring a client who is receiving opioid analgesia. Which of the following
findings should the nurse identify as adverse effects of opioid analgesics? (Select all
that apply).
A. Urinary incontinence.
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
E. Nausea. - ANSWERSC. Bradypnea
D. Orthostatic hypotension
E. Nausea.
Rationale: (C) Respiratory depression, which causes respiratory rates to drop to
dangerously low levels, is a common adverse effect of opioid analgesia (D) Dizziness or
lightheadedness when changing positions is a common adverse effect of opioid
analgesia (E) Nausea and vomiting are common adverse effects of opioid analgesia
A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's
assessment reveals positive Kernig's and Brudzinski's signs. Which of the following
actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplets precautions.
C. Initiate IV access
D. Decrease bright lights. - ANSWERSB. Implement droplets precautions.
Rationale: When using the urgent vs. nonurgent approach to care, the nurse determines
the priority action is to initiate droplet precautions when meningitis is suspected to
prevent spread of the disease to others.
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected
meningitis. Which of the following actions should the nurse take when performing this
technique? (Select all that apply).
A. Place cilent in supine position.
B. Flex client's hip and knee.
C. Place hands behind the client's neck.
D. Bend client's head toward chest.
E. Straighten the client's flexed leg at the knee. - ANSWERSA. Place cilent in supine
position.
C. Place hands behind the client's neck.
D. Bend client's head toward chest.
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