ATI CUSTOM: AH2- FA25- Exam 2
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Free ATI CUSTOM: AH2- FA25- Exam 2 Questions
1. A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply.)
- Falls
- Violence
- Sports-related injuries
- Working as a firefighter
- Working in a factory
Explanation
A. Falls
Falls are the most common cause of traumatic brain injuries, especially in older adults and young children. Head impact from losing balance or slipping can cause concussions, contusions, or intracranial bleeding. Prevention includes environmental safety and use of assistive devices.
B. Violence
Acts of violence such as assaults, gunshot wounds, and domestic abuse are major contributors to TBIs. Penetrating injuries or blunt force trauma can lead to severe brain damage or death, making this a significant preventable cause.
C. Sports-related injuries
Contact sports (football, boxing, hockey) and recreational activities can cause repetitive concussions or acute TBIs. Helmets and proper safety equipment help reduce risk, but athletes remain at high exposure to impact injuries.
Falls are the most common cause of traumatic brain injuries, especially in older adults and young children. Head impact from losing balance or slipping can cause concussions, contusions, or intracranial bleeding. Prevention includes environmental safety and use of assistive devices.
B. Violence
Acts of violence such as assaults, gunshot wounds, and domestic abuse are major contributors to TBIs. Penetrating injuries or blunt force trauma can lead to severe brain damage or death, making this a significant preventable cause.
C. Sports-related injuries
Contact sports (football, boxing, hockey) and recreational activities can cause repetitive concussions or acute TBIs. Helmets and proper safety equipment help reduce risk, but athletes remain at high exposure to impact injuries.
2. A client suffered burn injuries to their face and entire right arm and has an order for fluid resuscitation. The client weighs 80 kg. How much Lactated Ringer’s will be infused for the first 8 hours? (round to the nearest whole number)
- 1,080 mL
- 2,160 mL
- 3,240 mL
- 4,320 mL
Explanation
B. 2,160 mL
Let’s calculate step-by-step using the Parkland formula:
Parkland Formula: 4 mL × %TBSA burned × body weight (kg)
Given:
● %TBSA burned = face (4.5%) + entire right arm (9%) = 13.5%
● Weight = 80 kg
● Fluid = Lactated Ringer’s (LR)
● Total fluid for 24 hours = 4 × 13.5 × 80 = 4,320 mL
First 8 hours:
Half of the total volume is given in the first 8 hours.
4,320 ÷ 2 = 2,160 mL
Let’s calculate step-by-step using the Parkland formula:
Parkland Formula: 4 mL × %TBSA burned × body weight (kg)
Given:
● %TBSA burned = face (4.5%) + entire right arm (9%) = 13.5%
● Weight = 80 kg
● Fluid = Lactated Ringer’s (LR)
● Total fluid for 24 hours = 4 × 13.5 × 80 = 4,320 mL
First 8 hours:
Half of the total volume is given in the first 8 hours.
4,320 ÷ 2 = 2,160 mL
3. A nurse is planning care for a client who has neurogenic shock following a spinal cord injury. Which of the following provider prescriptions should the nurse anticipate? (Select all that apply.)
- Lactated Ringer’s intravenous fluid
- Epinephrine
- Furosemide
- Metoprolol
- Dopamine
Explanation
A. Lactated Ringer’s intravenous fluid
In neurogenic shock, hypotension occurs due to massive vasodilation from loss of sympathetic tone. Isotonic IV fluids such as Lactated Ringer’s help restore intravascular volume and maintain tissue perfusion until vasopressors are effective.
B. Epinephrine
Epinephrine acts as a vasoconstrictor and cardiac stimulant, increasing blood pressure and heart rate by stimulating both alpha and beta adrenergic receptors. It supports perfusion and combats the severe hypotension and bradycardia characteristic of neurogenic shock.
E. Dopamine
Dopamine is a vasopressor and inotropic agent that improves cardiac output and renal perfusion. It is often used to maintain mean arterial pressure (MAP ≥ 65 mm Hg) in clients with neurogenic shock when fluids alone are insufficient.
In neurogenic shock, hypotension occurs due to massive vasodilation from loss of sympathetic tone. Isotonic IV fluids such as Lactated Ringer’s help restore intravascular volume and maintain tissue perfusion until vasopressors are effective.
B. Epinephrine
Epinephrine acts as a vasoconstrictor and cardiac stimulant, increasing blood pressure and heart rate by stimulating both alpha and beta adrenergic receptors. It supports perfusion and combats the severe hypotension and bradycardia characteristic of neurogenic shock.
E. Dopamine
Dopamine is a vasopressor and inotropic agent that improves cardiac output and renal perfusion. It is often used to maintain mean arterial pressure (MAP ≥ 65 mm Hg) in clients with neurogenic shock when fluids alone are insufficient.
4. A burn patient requires fluid resuscitation following the injury. Which of the following actions is most appropriate for the nurse to take in assessing the need for fluid replacement in a burn patient?
- Restrict fluid intake to prevent electrolyte imbalances
- Weigh the patient weekly to assess fluid balance
- Administer diuretics to prevent fluid overload
- Monitor hourly urine output for a minimum of 30 mL/hr
Explanation
D. Monitor hourly urine output for a minimum of 30 mL/hr
In burn patients, urine output is the most reliable indicator of adequate fluid resuscitation. The nurse should monitor hourly urine output, maintaining at least 30 mL/hr (or 0.5 mL/kg/hr) in adults to ensure proper renal perfusion and tissue hydration. This measurement reflects the effectiveness of fluid replacement and guides adjustments in IV therapy. Adequate urine output signifies stable hemodynamics and sufficient circulating volume.
In burn patients, urine output is the most reliable indicator of adequate fluid resuscitation. The nurse should monitor hourly urine output, maintaining at least 30 mL/hr (or 0.5 mL/kg/hr) in adults to ensure proper renal perfusion and tissue hydration. This measurement reflects the effectiveness of fluid replacement and guides adjustments in IV therapy. Adequate urine output signifies stable hemodynamics and sufficient circulating volume.
5. Nurse's notes
A nurse is caring for a client in the intensive care unit (ICU) after a fall that experienced a spinal fracture.
Client transferred to ICU; care assumed at 0600. Transferred to hospital bed with spinal precautions in place. Client is aox4 GCS 15, pupils equal, round, and reactive to light. 3 to 2 mm bilaterally and brisk. Respirations tachypneic. unlabored, lungs clear to auscultation. Heart rate slow and regular, sinus bradycardia noted on monitor. Abdomen soft. nontender, bowel sounds hypoactive, urinary catheter in place draining to gravity. Absent rectal tone. Client unable to move lower extremities, flaccid paralysis noted to lower extremities bilaterally. Skins flushed and warm. Client denies pain currently. Safety maintained.
Vital signs
Temp 99.2F
Heart rate 52 bpm
Blood pressure 80/60 mmHg
Respiratory rate 22 bpm
SpO2 92% on room air
Pain 0/10
Diagnostics
CT thoracic spine reveals fracture and inflammation at T3
EKG: sinus bradycardia
Select the 3 findings below that indicate the client is progressing as expected (improving) (Select All that Apply.)
A nurse is caring for a client in the intensive care unit (ICU) after a fall that experienced a spinal fracture.
Client transferred to ICU; care assumed at 0600. Transferred to hospital bed with spinal precautions in place. Client is aox4 GCS 15, pupils equal, round, and reactive to light. 3 to 2 mm bilaterally and brisk. Respirations tachypneic. unlabored, lungs clear to auscultation. Heart rate slow and regular, sinus bradycardia noted on monitor. Abdomen soft. nontender, bowel sounds hypoactive, urinary catheter in place draining to gravity. Absent rectal tone. Client unable to move lower extremities, flaccid paralysis noted to lower extremities bilaterally. Skins flushed and warm. Client denies pain currently. Safety maintained.
Vital signs
Temp 99.2F
Heart rate 52 bpm
Blood pressure 80/60 mmHg
Respiratory rate 22 bpm
SpO2 92% on room air
Pain 0/10
Diagnostics
CT thoracic spine reveals fracture and inflammation at T3
EKG: sinus bradycardia
Select the 3 findings below that indicate the client is progressing as expected (improving) (Select All that Apply.)
- Bowel sounds present
- Oliguria
- Blood pressure increases
- Heart rate increases
- GCS decreases
Explanation
A. Bowel sounds present
The presence of bowel sounds indicates the return of gastrointestinal motility, which can be suppressed during spinal or neurogenic shock. This shows that autonomic nervous system activity is improving and that the client’s body is regaining normal function below the injury level.
C. Blood pressure increases
An increase in blood pressure from the previous hypotensive state (80/60 mmHg) demonstrates improved sympathetic tone and vascular stability. This is a key indicator that the effects of neurogenic shock are resolving and perfusion to vital organs is improving.
D. Heart rate increases
A heart rate rising from bradycardic levels (52 bpm) reflects recovery of sympathetic stimulation to the heart. This improvement shows stabilization of autonomic function and better cardiac output, both important for recovery after a high thoracic spinal injury.
The presence of bowel sounds indicates the return of gastrointestinal motility, which can be suppressed during spinal or neurogenic shock. This shows that autonomic nervous system activity is improving and that the client’s body is regaining normal function below the injury level.
C. Blood pressure increases
An increase in blood pressure from the previous hypotensive state (80/60 mmHg) demonstrates improved sympathetic tone and vascular stability. This is a key indicator that the effects of neurogenic shock are resolving and perfusion to vital organs is improving.
D. Heart rate increases
A heart rate rising from bradycardic levels (52 bpm) reflects recovery of sympathetic stimulation to the heart. This improvement shows stabilization of autonomic function and better cardiac output, both important for recovery after a high thoracic spinal injury.
6. A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- "To achieve a bowel movement, daily digital stimulation will need to be done."
- "Do not drink fluids excessively as this may cause diarrhea."
- "You will need to learn how to do self-intermittent catheterization to drain your bladder."
- "It will be necessary to take a stool softener to keep you from becoming constipated."
- "Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
Explanation
A. "To achieve a bowel movement, daily digital stimulation will need to be done."
Clients with complete spinal cord injuries lose voluntary control of bowel function. Digital stimulation or suppositories at consistent times each day help trigger reflex defecation and establish a regular bowel program.
C. "You will need to learn how to do self-intermittent catheterization to drain your bladder."
Neurogenic bladder is common after spinal cord injury. Intermittent catheterization every 4–6 hours helps prevent bladder overdistention, urinary retention, and infection while maintaining bladder health.
D. "It will be necessary to take a stool softener to keep you from becoming constipated."
Loss of bowel motility and decreased activity predispose clients to constipation. Stool softeners and adequate fiber and fluid intake help maintain bowel regularity and prevent impaction.
E. "Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
If the client cannot safely or effectively perform self-catheterization, a suprapubic catheter provides a long-term alternative for bladder drainage and reduces the risk of urethral trauma and infection.
Clients with complete spinal cord injuries lose voluntary control of bowel function. Digital stimulation or suppositories at consistent times each day help trigger reflex defecation and establish a regular bowel program.
C. "You will need to learn how to do self-intermittent catheterization to drain your bladder."
Neurogenic bladder is common after spinal cord injury. Intermittent catheterization every 4–6 hours helps prevent bladder overdistention, urinary retention, and infection while maintaining bladder health.
D. "It will be necessary to take a stool softener to keep you from becoming constipated."
Loss of bowel motility and decreased activity predispose clients to constipation. Stool softeners and adequate fiber and fluid intake help maintain bowel regularity and prevent impaction.
E. "Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
If the client cannot safely or effectively perform self-catheterization, a suprapubic catheter provides a long-term alternative for bladder drainage and reduces the risk of urethral trauma and infection.
7. A nurse is taking care of a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will keep cerebral perfusion pressure constant?
- Regulation of constriction and dilation of blood vessels in the brain
- Regulation of how much blood is pumped from the heart
- Regulation of catecholamines circulating throughout the body
- Regulation of the amount of carbon dioxide exhaled
Explanation
A. Regulation of constriction and dilation of blood vessels in the brain
The brain maintains a constant cerebral perfusion pressure (CPP) through cerebral autoregulation, which involves the constriction and dilation of cerebral blood vessels. This mechanism ensures stable blood flow to the brain despite fluctuations in systemic blood pressure. When perfusion pressure drops, cerebral vessels dilate to increase blood flow; when pressure rises, they constrict to prevent damage. This intrinsic regulation is essential for maintaining adequate oxygen and nutrient delivery to brain tissue.
The brain maintains a constant cerebral perfusion pressure (CPP) through cerebral autoregulation, which involves the constriction and dilation of cerebral blood vessels. This mechanism ensures stable blood flow to the brain despite fluctuations in systemic blood pressure. When perfusion pressure drops, cerebral vessels dilate to increase blood flow; when pressure rises, they constrict to prevent damage. This intrinsic regulation is essential for maintaining adequate oxygen and nutrient delivery to brain tissue.
8. A nurse is caring for a client who has increased intracranial pressure (ICP) and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)
- Respiratory rate of 12/min
- Changes to pupil size and shape
- Swelling of the optic nerve
- Blood pressure of 108/74 mm Hg
- Decreasing Glasgow Coma scores
Explanation
B. Changes to pupil size and shape
Alterations in pupil size, shape, or reactivity indicate pressure on cranial nerve III (oculomotor nerve) due to increased intracranial pressure. Unequal or fixed pupils suggest herniation or further compression of brain structures, requiring immediate intervention.
C. Swelling of the optic nerve
Papilledema, or optic nerve swelling, results from sustained ICP that impedes venous drainage in the optic nerve sheath. It is a key indicator of worsening intracranial pressure and may cause visual disturbances or blindness if not treated promptly.
E. Decreasing Glasgow Coma scores
A declining Glasgow Coma Scale (GCS) score reflects deteriorating neurologic function, signaling increased brain compression or decreased cerebral perfusion. Even a one-point drop is clinically significant and warrants immediate reassessment and provider notification.
Alterations in pupil size, shape, or reactivity indicate pressure on cranial nerve III (oculomotor nerve) due to increased intracranial pressure. Unequal or fixed pupils suggest herniation or further compression of brain structures, requiring immediate intervention.
C. Swelling of the optic nerve
Papilledema, or optic nerve swelling, results from sustained ICP that impedes venous drainage in the optic nerve sheath. It is a key indicator of worsening intracranial pressure and may cause visual disturbances or blindness if not treated promptly.
E. Decreasing Glasgow Coma scores
A declining Glasgow Coma Scale (GCS) score reflects deteriorating neurologic function, signaling increased brain compression or decreased cerebral perfusion. Even a one-point drop is clinically significant and warrants immediate reassessment and provider notification.
9. A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?
- Reposition the client every shift.
- Keep lights turned to medium level in the evening.
- Administer hypotonic intravenous solutions.
- Maintain the head of the bed between 30° and 45°.
Explanation
D. Maintain the head of the bed between 30° and 45°.
Keeping the head of the bed elevated between 30° and 45° helps reduce intracranial pressure (ICP) and promote venous drainage from the brain. In a client at risk of cerebral aneurysm rupture, preventing increases in ICP is essential because elevated pressure can trigger aneurysm rupture, resulting in subarachnoid hemorrhage. This position also aids in maintaining adequate cerebral perfusion pressure (CPP) while minimizing the risk of sudden vascular stress.
Keeping the head of the bed elevated between 30° and 45° helps reduce intracranial pressure (ICP) and promote venous drainage from the brain. In a client at risk of cerebral aneurysm rupture, preventing increases in ICP is essential because elevated pressure can trigger aneurysm rupture, resulting in subarachnoid hemorrhage. This position also aids in maintaining adequate cerebral perfusion pressure (CPP) while minimizing the risk of sudden vascular stress.
10. A nurse is performing a primary survey on a newly admitted client to the emergency room. Using the ABCDE assessment, which of the following areas are assessed under the "C" category?
- Mouth, larynx, and bronchi
- Heart and blood vessels
- Response to voice and pain
- Oxygen saturation and respiratory rate
Explanation
B. Heart and blood vessels
In the ABCDE primary survey, "C" stands for Circulation. During this stage, the nurse assesses the heart and blood vessels to determine the adequacy of perfusion and identify any life-threatening bleeding or circulatory compromise. Assessment includes checking pulse (rate, rhythm, quality), blood pressure, skin color and temperature, capillary refill, and looking for signs of hemorrhage or shock. The goal is to ensure effective cardiac output and tissue perfusion.
In the ABCDE primary survey, "C" stands for Circulation. During this stage, the nurse assesses the heart and blood vessels to determine the adequacy of perfusion and identify any life-threatening bleeding or circulatory compromise. Assessment includes checking pulse (rate, rhythm, quality), blood pressure, skin color and temperature, capillary refill, and looking for signs of hemorrhage or shock. The goal is to ensure effective cardiac output and tissue perfusion.
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