ATI Quiz NR325 Unit 4 & 5 quiz- Edfort 1 Detailed Answer Key Graded A

ATI Quiz NR325 Unit 4 & 5 quiz- Edfort 1 Detailed Answer Key Graded A 1. A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A. A change in the Glasgow Coma Scale score from 13 to 11 Rationale: In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider. B. Diplopia Rationale: In a client who has mild TBI, diplopia indicates a risk for damage to the optic tract and should be reported to the provider; however, another finding is the priority to report. C. A drop in heart rate from 76 to 70/min Rationale: In a client who has mild TBI, a decrease in heart rate indicates that the client is at risk for increasing intracranial pressure, but this client's heart rate has not dropped below 60/min. Therefore, another finding is the priority to report. D. Ataxia Rationale: In a client who has mild TBI, ataxia indicates a risk for brainstem or cerebellar injury and should be reported to the provider; however, another finding is the priority. 2. A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to read following a stroke would have involvement of the left hemisphere. B. Inability to recognize his family members Rationale: The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere. C. Right hemiparesis Rationale: The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the body reflects damage to the upper motor neurons on the opposite side of the brain. A client who has right hemiparesis would have involvement of the left hemisphere. D. Aphasia Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to speak or understand language following a stroke would have involvement of the left hemisphere.