ATI MEDSURG FINAL EXAM NEWEST 2024 ACTUAL EXAM COMPLETE 400 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed.
Which of the following findings indicates that the client is experiencing increased intracranial pressure
(ICP)? (Select all that apply)
-Flat jugular veins
-A Glasgow Coma Scale score of 15
-Sleepiness exhibited by the client
-Widening pulse pressure
-Decerebrate posturing - (answer) Correct:
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an
indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent
decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP.
Signs of increased ICP: - (answer) Irritability
Severe headache
Distended jugular veins
Decreased LOC (Glascow coma scale would not be 15).
Dilated or pinpoint pupils
Altered breathing (cheyne-stokes, hyperventilation, apnea)
Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP.
Widening pulse pressure. A widening pulse pressure (increase in systolic with concurrent decrease in
diastolic blood pressure) is an indication of increased ICP.
Abnormal posturing. Both decerebrate and decorticate posturing indicate increased ICP.
Normal ICP: - (answer) 10-15
, ATI MEDSURG FINAL EXAM NEWEST 2024 ACTUAL EXAM COMPLETE 400 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
Pulse pressure - (answer) The difference between the systolic and diastolic pressures.
Cheyne-stokes - (answer) Regular cycle where the rate and depth of breathing increase, then decrease
until apnea (usually about 20 seconds) occurs Duration of apnea may vary and progressively lengthen;
therefore, it is timed and reported. Associated with heart failure and damage to the respiratory center
(drug induced, tumor, trauma)
Hyper ventilation - (answer) Increased rate and depth of breathing that results in decreased PaCO2
level Inspiration and expiration nearly equal in duration Associated with exertion, anxiety, and metabolic
acidosis Called Kussmaul's respiration if associated with diabetic ketoacidosis or renal origin
Biot's respiration - (answer) Periods of normal breathing (3-4 breaths), followed by a varying period of
apnea (usually 10-60 seconds) Also called ataxic breathing; associated with complete irregularity
Associated with respiratory depression resulting from drug overdose and brain injury, normally at the
level of the medulla
Cheyne-stokes vs Biot's respirations - (answer) There are subtle differences between Cheyne-Stokes
and Biot's respiration patterns. Between regularly cycled periods of apnea, Cheyne-Stokes respirations
demonstrate a regular pattern with the rate and depth of breathing increasing and then decreasing. In
Biot's respiration, irregularly cycled periods of apnea are interspersed with cycles of normal rate and
depth.
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of
the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to
cardioversion?
-Enoxaparin
-Metformin
-Diazepam
-Digoxin - (answer) Correct:
Digoxin
DETAILED ANSWERS WITH RATIONALES
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed.
Which of the following findings indicates that the client is experiencing increased intracranial pressure
(ICP)? (Select all that apply)
-Flat jugular veins
-A Glasgow Coma Scale score of 15
-Sleepiness exhibited by the client
-Widening pulse pressure
-Decerebrate posturing - (answer) Correct:
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an
indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent
decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP.
Signs of increased ICP: - (answer) Irritability
Severe headache
Distended jugular veins
Decreased LOC (Glascow coma scale would not be 15).
Dilated or pinpoint pupils
Altered breathing (cheyne-stokes, hyperventilation, apnea)
Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP.
Widening pulse pressure. A widening pulse pressure (increase in systolic with concurrent decrease in
diastolic blood pressure) is an indication of increased ICP.
Abnormal posturing. Both decerebrate and decorticate posturing indicate increased ICP.
Normal ICP: - (answer) 10-15
, ATI MEDSURG FINAL EXAM NEWEST 2024 ACTUAL EXAM COMPLETE 400 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
Pulse pressure - (answer) The difference between the systolic and diastolic pressures.
Cheyne-stokes - (answer) Regular cycle where the rate and depth of breathing increase, then decrease
until apnea (usually about 20 seconds) occurs Duration of apnea may vary and progressively lengthen;
therefore, it is timed and reported. Associated with heart failure and damage to the respiratory center
(drug induced, tumor, trauma)
Hyper ventilation - (answer) Increased rate and depth of breathing that results in decreased PaCO2
level Inspiration and expiration nearly equal in duration Associated with exertion, anxiety, and metabolic
acidosis Called Kussmaul's respiration if associated with diabetic ketoacidosis or renal origin
Biot's respiration - (answer) Periods of normal breathing (3-4 breaths), followed by a varying period of
apnea (usually 10-60 seconds) Also called ataxic breathing; associated with complete irregularity
Associated with respiratory depression resulting from drug overdose and brain injury, normally at the
level of the medulla
Cheyne-stokes vs Biot's respirations - (answer) There are subtle differences between Cheyne-Stokes
and Biot's respiration patterns. Between regularly cycled periods of apnea, Cheyne-Stokes respirations
demonstrate a regular pattern with the rate and depth of breathing increasing and then decreasing. In
Biot's respiration, irregularly cycled periods of apnea are interspersed with cycles of normal rate and
depth.
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of
the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to
cardioversion?
-Enoxaparin
-Metformin
-Diazepam
-Digoxin - (answer) Correct:
Digoxin
