SOLVED - ATI Learning System - Adult Med-Surg Critical Care Practice III-Questions & Answers Updated for 2023

ATI Learning System - Adult Med-Surg Critical Care Practice III-Questions & Answers Updated for 2023Practice III Questions & Answers Updated for 2023 a,d,e,f - Ans | A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? (Select all that apply). a. Nausea and vomiting b. Hyperthermia c. Bradycardia d. Increased weight e. Decreased serum sodium f. Decreased level of consciousness a,b - Ans | A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? (Select all that apply). a. Irritability b. Bradycardia c. Hyperalertness d. Decreased pulse pressure e. Decreased systolic blood pressure a - Ans | What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? a. Monitor the client for signs of brain injury. b. Check for hemorrhaging from the oral and nasal cavities. c. Elevate the foot of the bed if the client develops symptoms of shock. d. Observe for clinical indicators of decreased intracranial pressure and temperature. a,b,e - Ans | The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? (Select all that apply). a. Vomiting b. Irritability c. Hypotension d. Increased respirations e. Decreased level of consciousness a - Ans | The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma? a. 6 b. 9 c. 12 d. 15 a - Ans | A client is scheduled for a computed tomography (CT) of the brain with contrast. When reviewing the client's medical record, what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure? a. The client takes metformin daily. b. The client has not been nothing by mouth (NPO). c. The client reports an allergy to gadolinium. d. The client was not prescribed a bowel prep. d - Ans | After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH? a. Serum osmolarity increases b. Urine concentration decreases c. Glomerular filtration decreases d. Tubular reabsorption of water increases a,d,e - Ans | What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? (Select all that apply). a. Providing adequate fluids within easy reach b. Reporting an increasing urine specific gravity c. Administering prescribed erythromycin d. Assessing for and reporting changes in neurological status e. Monitoring for constipation, weight loss, hypotension, and tachycardia c - Ans | A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? a. Increased serum glucose b. Deficient renal perfusion c. Inadequate antidiuretic hormone (ADH) secretion d. Excess amounts of intravenous (IV) fluid c - Ans | After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? a. Increased blood urea nitrogen (BUN) and hypotension b. Hyperkalemia and poor skin turgor c. Hyponatremia and decreased urine output d. Polyuria and increased specific gravity of urine c - Ans | A construction worker fell off the roof of a two-story building and was taken to the hospital in an unconscious state. During the initial assessment, what clinical finding should the nurse report immediately? a. Reactive pupils b. Depressed fontanel c. Bleeding from the ears d. Increased body temperature d - Ans | After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority? a. Moving the client as little as possible b. Preparing the client for mannitol administration c. Stimulating the client to maintain responsiveness d. Monitoring the client for increasing intracranial pressure d - Ans | A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO 2 of 33 mm Hg. What action is most important for the nurse to take? a. Encourage the client to slow the breathing rate. b. Auscultate the client's lungs and suction if indicated. c. Advise the healthcare provider that the client needs supplemental oxygen. d. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure. d - Ans | Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? a. Spinal shock b. Hypovolemic shock c. Transtentorial herniation d. Increasing intracranial pressure a - Ans | A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP?