ATI 2025 Targeted Medical-Surgical:
Neurosensory & Musculoskeletal – Accurate
Questions and Correct Answers
A nurse is planning care for a client who has a closed traumatic brain injury from a
fall and is receiving mechanical ventilation. Which of the following intervention is the
nurse's priority?
A. Maintain a PaCO2 of approx. 35 mmHg
B. Provide small doses of fentanyl via bolus for pain management
C. Measure body temperature every 1-2hr - CORRECT ANSWER ✅✅✅A.
Maintain a PaCO2 of approx. 35 mmHg
The greatest risk to this client is injury from increased intracranial pressure.
Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35
mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to
increase in intracranial pressure.
A nurse is caring for a client who has a retinal detachment. which of the following
findings should the nurse expect?
A. Photophobia
B. Complete vision loss
C. Flashes of bright light
D. Cloudiness of the lends - CORRECT ANSWER ✅✅✅C. Flashes of bright light
The nurse should expect a client who has a retinal detachment to see flashes of
bright light or floating dark spots in the affected eye as the retinal layers separate.
Photophobia - The nurse should expect photophobia in a client who has a migraine
headache.
Complete vision loss
-The nurse should expect a client who has a retinal detachment to have some visual
field loss in the area of the detachment, but complete vision loss is not an expected
finding.
Cloudiness of the lens- The nurse should expect a client who has cataracts to
experience cloudiness of the lens
A nurse is caring for a client who has a spastic bladder following a spinal cord injury.
Which of the following actions should the nurse take to help stimulate micturition?
A. Encourage the client to use the Valvalsa maneuver
B. Stroke the client's inner thigh
C. Perform the Crede maneuver
D. Administer a diuretic - CORRECT ANSWER ✅✅✅B. Stroke the client's inner
thigh
, The nurse should stimulate micturition by stroking the client's inner thigh. Other
techniques include pinching the skin above the groin and providing digital anal
stimulation.
Perform the Credé maneuver.The nurse should apply direct pressure over the
client's bladder, also known as the Credé maneuver, to express urine from a flaccid
bladder. It is not effective for clients who have a spastic bladder due to the spasticity
of the external sphincter.
Administer a diuretic.Antispasmodics such as oxybutynin, rather than diuretics, can
be effective for treating mild spastic bladder problems.
Encourage the client to use the Valsalva maneuver.-The nurse should encourage the
client to hold their breath and bear down, also known as the Valsalva maneuver, to
express urine from a flaccid bladder. It is not effective for clients who have a spastic
bladder due to the spasticity of the external sphincter.
A nurse is caring for a client who has viral meningitis. Which of the following actions
should the nurse take?
A. Assess the client's neurologic status every 8 hr
B. Initiate droplet precautions
C. Check capillary refill at least every 4 hr
D. Place the client in a well-lit environment - CORRECT ANSWER ✅✅✅C.
Check capillary refill at least every 4hr-The nurse should perform a complete
vascular assessment at least every 4 hr to monitor for vascular compromise
Place the client in a well-lit environment.
The nurse should minimize the client's exposure to light from windows and overhead
lights because photophobia, or light sensitivity, is a manifestation of viral meningitis.
Assess the client's neurologic status every 8 hr.The nurse should assess the client's
vital signs and neurologic status at least every 2 to 4 hr.
Initiate droplet precautions.-The nurse should implement droplet precautions for
clients who have bacterial meningitis. Standard precautions are sufficient for clients
who have viral meningitis.
A nurse is caring for a client who has a history of status epilepticus and requires
seizure precautions. Which of the following actions should the nurse take?
A. Assess hourly for a spike in blood pressure
B. Keep the client on bed rest
C. Keep a padded tongue blade at the bedside
D. Establish IV access - CORRECT ANSWER ✅✅✅D. Establish IV access-The
nurse should plan to establish IV access with a large-bore catheter and administer
0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse
should initiate a saline lock.
Assess hourly for a spike in blood pressure.The nurse should check the client's vital
signs and perform neurological checks after a seizure. However, a change in blood
pressure does not correlate with an increased incidence of seizure activity.
Keep the client on bed rest.A client who is at risk for seizures does not require bed
rest. However, if seizures are imminent or frequent, the nurse should institute safety
Neurosensory & Musculoskeletal – Accurate
Questions and Correct Answers
A nurse is planning care for a client who has a closed traumatic brain injury from a
fall and is receiving mechanical ventilation. Which of the following intervention is the
nurse's priority?
A. Maintain a PaCO2 of approx. 35 mmHg
B. Provide small doses of fentanyl via bolus for pain management
C. Measure body temperature every 1-2hr - CORRECT ANSWER ✅✅✅A.
Maintain a PaCO2 of approx. 35 mmHg
The greatest risk to this client is injury from increased intracranial pressure.
Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35
mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to
increase in intracranial pressure.
A nurse is caring for a client who has a retinal detachment. which of the following
findings should the nurse expect?
A. Photophobia
B. Complete vision loss
C. Flashes of bright light
D. Cloudiness of the lends - CORRECT ANSWER ✅✅✅C. Flashes of bright light
The nurse should expect a client who has a retinal detachment to see flashes of
bright light or floating dark spots in the affected eye as the retinal layers separate.
Photophobia - The nurse should expect photophobia in a client who has a migraine
headache.
Complete vision loss
-The nurse should expect a client who has a retinal detachment to have some visual
field loss in the area of the detachment, but complete vision loss is not an expected
finding.
Cloudiness of the lens- The nurse should expect a client who has cataracts to
experience cloudiness of the lens
A nurse is caring for a client who has a spastic bladder following a spinal cord injury.
Which of the following actions should the nurse take to help stimulate micturition?
A. Encourage the client to use the Valvalsa maneuver
B. Stroke the client's inner thigh
C. Perform the Crede maneuver
D. Administer a diuretic - CORRECT ANSWER ✅✅✅B. Stroke the client's inner
thigh
, The nurse should stimulate micturition by stroking the client's inner thigh. Other
techniques include pinching the skin above the groin and providing digital anal
stimulation.
Perform the Credé maneuver.The nurse should apply direct pressure over the
client's bladder, also known as the Credé maneuver, to express urine from a flaccid
bladder. It is not effective for clients who have a spastic bladder due to the spasticity
of the external sphincter.
Administer a diuretic.Antispasmodics such as oxybutynin, rather than diuretics, can
be effective for treating mild spastic bladder problems.
Encourage the client to use the Valsalva maneuver.-The nurse should encourage the
client to hold their breath and bear down, also known as the Valsalva maneuver, to
express urine from a flaccid bladder. It is not effective for clients who have a spastic
bladder due to the spasticity of the external sphincter.
A nurse is caring for a client who has viral meningitis. Which of the following actions
should the nurse take?
A. Assess the client's neurologic status every 8 hr
B. Initiate droplet precautions
C. Check capillary refill at least every 4 hr
D. Place the client in a well-lit environment - CORRECT ANSWER ✅✅✅C.
Check capillary refill at least every 4hr-The nurse should perform a complete
vascular assessment at least every 4 hr to monitor for vascular compromise
Place the client in a well-lit environment.
The nurse should minimize the client's exposure to light from windows and overhead
lights because photophobia, or light sensitivity, is a manifestation of viral meningitis.
Assess the client's neurologic status every 8 hr.The nurse should assess the client's
vital signs and neurologic status at least every 2 to 4 hr.
Initiate droplet precautions.-The nurse should implement droplet precautions for
clients who have bacterial meningitis. Standard precautions are sufficient for clients
who have viral meningitis.
A nurse is caring for a client who has a history of status epilepticus and requires
seizure precautions. Which of the following actions should the nurse take?
A. Assess hourly for a spike in blood pressure
B. Keep the client on bed rest
C. Keep a padded tongue blade at the bedside
D. Establish IV access - CORRECT ANSWER ✅✅✅D. Establish IV access-The
nurse should plan to establish IV access with a large-bore catheter and administer
0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse
should initiate a saline lock.
Assess hourly for a spike in blood pressure.The nurse should check the client's vital
signs and perform neurological checks after a seizure. However, a change in blood
pressure does not correlate with an increased incidence of seizure activity.
Keep the client on bed rest.A client who is at risk for seizures does not require bed
rest. However, if seizures are imminent or frequent, the nurse should institute safety
