ATI PN LEARNING SYSTEM MEDICAL-SURGICAL NEUROSENSORY PRACTICE QUESTIONS WITH COMPLETE AND ACCURATE SOLUTIONS

ATI PN LEARNING SYSTEM MEDICAL-SURGICAL: NEUROSENSORY
PRACTICE QUESTIONS WITH COMPLETE AND ACCURATE
SOLUTIONS.


1) A nurse in an acute care facility is preparing to admit a client who has myasthenia
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gravis. Which of the following supplies should the nurse place at the client's
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bedside? -- Correct Answer ✔✔ Oral-nasal suction equipment
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The client who has myasthenia gravis is at risk for aspiration because of
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progressive weakness of the oropharyngeal muscles. Myasthenia gravis__ __ __ __ __ __ __ __




causes muscle weakness due to an autoimmune disease that affects the
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acetylcholine receptors. The nurse should place oxygen and oral-nasal __ __ __ __ __ __ __ __ __




suction equipment at the bedside in the event of aspiration or respiratory
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distress.

2) A nurse in a rehabilitation center is collecting data from a client who is recovering
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from a left-hemisphere stroke. Which of the following findings should the nurse
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expect? -- Correct Answer ✔✔ Difficulty with speech
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The left hemisphere of the brain is usually the dominant side and is
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responsible for language. This is always true for right-handed clients and for
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the majority of left-handed clients. Since this client is recovering from a
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left-hemisphere stroke, the nurse should anticipate that the client will have __ __ __ __ __ __ __ __ __ __ __




aphasia and require speech therapy to establish communication.
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3) A nurse is reinforcing teaching with a class of new parents about otitis media.
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Which of the following manifestations should the nurse include in the teaching? --
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Correct Answer ✔✔ Feeling of fullness in the ear
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A client who has otitis media can develop a feeling of fullness in the ear.
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Other manifestations can include ear pain, a crackling sound when yawning
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or swallowing, and mild dizziness.
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, 4) A nurse is caring for a client who has a closed head injury. The nurse should place
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the client in which of the following positions? -- Correct Answer ✔✔ Semi-
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Fowler's

To prevent an increase in intracranial pressure, the nurse should position
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the client with his head midline and the head of the bed elevated 30
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degrees. This positioning permits blood flow to the client's brain while
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allowing venous drainage, thereby decreasing the postoperative risk of
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increased intracranial pressure. __ __




5) A nurse is caring for a client who has a traumatic brain injury and assumes a
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decerebrate posture in response to noxious stimuli. Which of the following
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reactions should the nurse anticipate when drawing a blood sample? -- Correct
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Answer ✔✔ A client who exhibits a decerebrate posture rigidly extends and
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pronates his four extremities and externally rotates his wrists. Decerebrate
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posturing indicates severe brain stem injury and late neurologic decline.
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6) A nurse is collecting data from a client who is admitted to the facility for
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observation following a closed head injury. Which of the following data is the
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priority for the nurse to collect to detect a change in the client's neurologic
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status? -- Correct Answer ✔✔ Level of consciousness
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The nurse should apply the urgent vs. nonurgent priority-setting
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framework. Using this framework, the nurse should consider urgent needs __ __ __ __ __ __ __ __ __ __




the priority because they pose more of a risk to the client. The nurse might
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also use Maslow's Hierarchy of Needs, the ABC priority-setting
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framework, or nursing knowledge to identify the most urgent finding. __ __ __ __ __ __ __ __ __ __




Therefore, the priority data collection is level of consciousness. A change __ __ __ __ __ __ __ __ __ __ __




in the client's level of consciousness can be the first indication of a change
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in neurologic status.
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7) A nurse is collecting data from a client who has a new diagnosis of acute angle-
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closure glaucoma. The nurse should anticipate the client to report which of the
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following manifestations? -- Correct Answer ✔✔ Severe eye pain
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