ATI Med-Surg Exam 2 (3 Versions) 2021/2022 Graded A+ Exam 2 Version 1

1. A client who experienced a stroke on the left side of the brain suddenly begins to get angry and frustrated while playing a card game. What is the best action by the rehabilitation nurse? a. Reassure the client that there is nothing to be angry about b. Ask the client what made him or her angry c. Ask the client to stop behaving inappropriately d. Distract the client 2. Admission vital signs for a brain-injured client are blood pressure 128/68 mm Hg, pulse of 110 BPM, and respirations of 26. Which set of vital signs, if taken 1 hour after admission, will be of the most concern to the nurse? a. BP 154/68 mm Hg, Pulse 56 BPM, RR 12 b. BP 134/72 mm Hg, Pulse 90 BPM, RR 32 c. BP 110/70 mm Hg, Pulse 120 BPM, RR 32 d. BP 148/78 mm Hg, Pulse 112 BPM, RR 28 3. A client is at the emergency room with suspected spinal cord and head injuries has a Glasgow Coma scale of 15; blood pressure 133/84 mm Hg, pulse of 102 bpm, RR 19 and temperature of 98F (36.6C). What is the most important nursing intervention during the initial care of the client ? a. Avoid moving the client b. Keep the head of the bed elevated 30 degrees c. Check the extremities for range of motion d. Turn the client to the side to avoid aspiration Spinal precautions include BED REST, NO NECK FLEXION WITH A PILLOW OR ROLL, NO THORACIC OR LUMBAR FLEXION WITH HOB ELEVATION/BED CONTROLS (REVERSE TRENDELENBURG IS ACCEPTABLE). Rigid cervical collar or long spine board are used to prevent new or secondary spine injury if there is unstable vertebrae or ligament damage. 4. A client with acute ischemic stroke is ordered to receive alteplase. The client weighs 160.6 lbs. Based on standard alteplase administration for stroke, how many mL per hour will the nurse run bolus? a. 386 b. 1 c. 3864 d. 65.7 5. A client receiving cyclosporine must be taught which of the following? a. It’s alright to continue working at a daycare b. Report signs of dark urine and yellowing of the skin c. Nausea is an expected side effect d. Bruising is an expected side effect. Cyclosporine main side effect is Nephrotoxicity. (PAGE 302) 6. A client is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the client’s GCS score. When assessing the client’s best motor response, which movement would receive the lowest score? a. Abnormal extension b. Decorticate posturing c. Withdrawing from pain d. Localizing Pain MOTOR RESPONSE OBEYS COMMANDS – 6 LOCALIZES PAIN – 5 NORMAL FLEXION (WITHDRAWAL) – 4 ABNORMAL FLEXION (DECORTICATE POSTURING) – 3 EXTENSION (DECEBERATE) – 2 NONE – 1 7. The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure the client reaches over with his left hand and tries to remove the noxious (an