ATI EXIT EXAM MED SURG II
1.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.:
B. 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,
1/
106
,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
2.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: B. Infection
Rationale: The nurse should monitor a client who has a ventriculostomy
2/
106
,for infection, which is a complication. The nurse should use strict
asepsis to avoid this life-threat- ening condition, which can result in
meningitis.
3.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
3/
106
, D. E2 + V2 + M4 = 8: B. E3 + V4 + M4 = 11
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.
4.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.": A. "I think I might be pregnant."
4/
106
1.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.:
B. 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,
1/
106
,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
2.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: B. Infection
Rationale: The nurse should monitor a client who has a ventriculostomy
2/
106
,for infection, which is a complication. The nurse should use strict
asepsis to avoid this life-threat- ening condition, which can result in
meningitis.
3.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
3/
106
, D. E2 + V2 + M4 = 8: B. E3 + V4 + M4 = 11
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.
4.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.": A. "I think I might be pregnant."
4/
106
