ATI CUSTOM: AH2- FA25- Exam 2
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Free ATI CUSTOM: AH2- FA25- Exam 2 Questions
1. A nurse is caring for a client who has a spinal cord injury.
Nurses' Notes
0810:
Client lying supine in bed. Skin warm and dry. Awake, alert, and oriented x 4. Lung sounds clear. Heart sounds regular, peripheral pulses palpable 3+ in upper and lower extremities. Normoactive bowel sounds in all 4 quadrants. 1+ edema noted to right lower extremity. Reports pain as 3 on a scale of 0 to 10.
1356:
Client with 4+ edema noted to right calf with inflammation and irritation noted. Calf has increased warmth compared to left leg. Client reports calf pain as 5 on a scale of 0 to 10. Right pedal pulse 3+. Provider notified.
Which of the following findings should the nurse identify as requiring immediate follow-up? Select the "3" findings that require immediate follow-up.
Nurses' Notes
0810:
Client lying supine in bed. Skin warm and dry. Awake, alert, and oriented x 4. Lung sounds clear. Heart sounds regular, peripheral pulses palpable 3+ in upper and lower extremities. Normoactive bowel sounds in all 4 quadrants. 1+ edema noted to right lower extremity. Reports pain as 3 on a scale of 0 to 10.
1356:
Client with 4+ edema noted to right calf with inflammation and irritation noted. Calf has increased warmth compared to left leg. Client reports calf pain as 5 on a scale of 0 to 10. Right pedal pulse 3+. Provider notified.
Which of the following findings should the nurse identify as requiring immediate follow-up? Select the "3" findings that require immediate follow-up.
- Pedal pulses of right leg 3+
- 4+ edema to right leg
- Inflammation and irritation on right calf
- Warmth on right leg
- Capillary refill less than 3 seconds in right great toe
Explanation
B. 4+ edema to right leg
Severe (4+) edema in one leg is an urgent finding indicating possible venous obstruction, such as a deep vein thrombosis (DVT). The rapid progression from 1+ to 4+ edema suggests acute vascular compromise, requiring immediate follow-up and diagnostic evaluation to prevent embolization or pulmonary embolism.
C. Inflammation and irritation on right calf
Localized redness and irritation are classic signs of venous inflammation. These symptoms, combined with unilateral swelling and tenderness, strongly suggest DVT development. Prompt reporting and intervention, including diagnostic testing and anticoagulation, are essential to prevent life-threatening complications.
D. Warmth on right leg
Increased warmth indicates localized inflammation and venous stasis associated with thrombus formation. This, along with swelling and pain, is part of the clinical triad for DVT. It signals compromised venous return and warrants urgent medical evaluation.
Severe (4+) edema in one leg is an urgent finding indicating possible venous obstruction, such as a deep vein thrombosis (DVT). The rapid progression from 1+ to 4+ edema suggests acute vascular compromise, requiring immediate follow-up and diagnostic evaluation to prevent embolization or pulmonary embolism.
C. Inflammation and irritation on right calf
Localized redness and irritation are classic signs of venous inflammation. These symptoms, combined with unilateral swelling and tenderness, strongly suggest DVT development. Prompt reporting and intervention, including diagnostic testing and anticoagulation, are essential to prevent life-threatening complications.
D. Warmth on right leg
Increased warmth indicates localized inflammation and venous stasis associated with thrombus formation. This, along with swelling and pain, is part of the clinical triad for DVT. It signals compromised venous return and warrants urgent medical evaluation.
2. A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?
- Reduce the temperature in the room
- Lower blood pressure
- Hyperventilate the client
- Decrease sedation
Explanation
C. Hyperventilate the client
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
3. A client with a spinal cord injury was given IV dexamethasone (Decadron) after arriving in the emergency department. What assessment finding should the nurse attribute to the steroid medication?
- Lessen spinal shock
- Muscle spasms
- Urinary retention
- Paralysis
Explanation
A. Lessen spinal shock
Dexamethasone (Decadron) is a corticosteroid that reduces inflammation and edema around the spinal cord following injury. By minimizing swelling and secondary tissue damage, it can improve neurological function and lessen the severity of spinal shock. This results in better perfusion to the injured area and preservation of nerve function, reducing complications associated with cord compression.
Dexamethasone (Decadron) is a corticosteroid that reduces inflammation and edema around the spinal cord following injury. By minimizing swelling and secondary tissue damage, it can improve neurological function and lessen the severity of spinal shock. This results in better perfusion to the injured area and preservation of nerve function, reducing complications associated with cord compression.
4. A nurse is caring for a client who recently sustained a burn. Which of the following would cue the nurse to be alert for the potential for inhalation injury?
- The burn happened at a bonfire.
- The burn was self-inflicted.
- The burn occurred inside of a home.
- The burn was a result of an electrocution.
Explanation
C. The burn occurred inside of a home
Burns that occur inside an enclosed space, such as a home, raise immediate concern for inhalation injury due to smoke, superheated air, or toxic gas exposure (e.g., carbon monoxide, cyanide). These conditions can damage the airway and lungs even when external burns seem minor. The nurse should assess for soot in the mouth or nose, singed nasal hairs, hoarseness, stridor, or carbonaceous sputum, and be prepared for early airway management.
Burns that occur inside an enclosed space, such as a home, raise immediate concern for inhalation injury due to smoke, superheated air, or toxic gas exposure (e.g., carbon monoxide, cyanide). These conditions can damage the airway and lungs even when external burns seem minor. The nurse should assess for soot in the mouth or nose, singed nasal hairs, hoarseness, stridor, or carbonaceous sputum, and be prepared for early airway management.
5. A nurse is caring for a client in the intensive care unit (ICU) after a fall that experienced a spinal fracture.
Nurse's notes
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
Which four findings require immediate follow up (Select All that Apply.)
Nurse's notes
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
Which four findings require immediate follow up (Select All that Apply.)
- Heart rate
- CT scan results
- Skins flushed
- GCS 15
- Blood pressure
Explanation
A. Heart rate
A heart rate of 52 bpm indicates bradycardia, which is a critical sign of neurogenic shock resulting from disruption of sympathetic input to the heart. The nurse must immediately notify the provider and prepare for interventions such as IV fluids or atropine to maintain perfusion.
B. CT scan results
The CT scan showing a T3 spinal fracture with inflammation confirms a high thoracic injury, which places the client at significant risk for neurogenic shock and respiratory compromise. This finding requires immediate follow-up for stabilization and prevention of further spinal cord damage.
C. Skins flushed
Warm, flushed skin occurs because of loss of sympathetic tone, leading to massive vasodilation and poor thermoregulation—another hallmark of neurogenic shock. This sign, combined with bradycardia and hypotension, signals hemodynamic instability.
E. Blood pressure
A blood pressure of 80/60 mmHg reflects severe hypotension due to loss of vasomotor control below the level of injury. It requires immediate intervention with fluids and possibly vasopressors to maintain adequate cerebral and organ perfusion.
A heart rate of 52 bpm indicates bradycardia, which is a critical sign of neurogenic shock resulting from disruption of sympathetic input to the heart. The nurse must immediately notify the provider and prepare for interventions such as IV fluids or atropine to maintain perfusion.
B. CT scan results
The CT scan showing a T3 spinal fracture with inflammation confirms a high thoracic injury, which places the client at significant risk for neurogenic shock and respiratory compromise. This finding requires immediate follow-up for stabilization and prevention of further spinal cord damage.
C. Skins flushed
Warm, flushed skin occurs because of loss of sympathetic tone, leading to massive vasodilation and poor thermoregulation—another hallmark of neurogenic shock. This sign, combined with bradycardia and hypotension, signals hemodynamic instability.
E. Blood pressure
A blood pressure of 80/60 mmHg reflects severe hypotension due to loss of vasomotor control below the level of injury. It requires immediate intervention with fluids and possibly vasopressors to maintain adequate cerebral and organ perfusion.
6. 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.
7. 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.
8. A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?
- Consulting an allergy specialist
- Assessing the client's neurologic status
- Determining the cause of the hives
- Administering epinephrine
Explanation
D. Administering epinephrine
The client is exhibiting signs of anaphylaxis—a life-threatening allergic reaction characterized by airway swelling (swollen tongue), wheezing, and hives. The priority is to maintain airway patency and prevent cardiovascular collapse. Epinephrine is the first-line emergency treatment because it rapidly causes bronchodilation, vasoconstriction, and reversal of airway edema. The nurse should administer IM epinephrine (1:1000 concentration) immediately, followed by airway management, oxygen, and IV access.
The client is exhibiting signs of anaphylaxis—a life-threatening allergic reaction characterized by airway swelling (swollen tongue), wheezing, and hives. The priority is to maintain airway patency and prevent cardiovascular collapse. Epinephrine is the first-line emergency treatment because it rapidly causes bronchodilation, vasoconstriction, and reversal of airway edema. The nurse should administer IM epinephrine (1:1000 concentration) immediately, followed by airway management, oxygen, and IV access.
9. When planning immediate care for a client with moderate burns, what interventions should the nurse anticipate providing? (Select all that apply.)
- Use of topical antibiotics on the wounds
- Application of ice packs to the burned areas
- Mechanical ventilation for severe respiratory deterioration
- Laboratory studies to determine fluid-volume status
- Administration of tetanus immunization
- Immediate IV access with Lactated Ringer’s solution
Explanation
A. Use of topical antibiotics on the wounds
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
10. A nurse is explaining the pathophysiology of systemic inflammatory response syndrome (SIRS) to a group of newly licensed nurses. Which of the following statements by the nurse is accurate?
- "Spleen dysfunction causes blood clotting issues."
- "The major organ prone to injury during SIRS is the heart."
- "Activation of the inflammatory cascade causes increased perfusion."
- "A deregulated cytokine storm causes an inflammatory response."
Explanation
D. "A deregulated cytokine storm causes an inflammatory response."
Systemic Inflammatory Response Syndrome (SIRS) results from a dysregulated immune response, where excessive cytokine release (a cytokine storm) triggers widespread inflammation. This causes vasodilation, increased capillary permeability, and tissue edema, leading to impaired tissue perfusion and potential multi-organ dysfunction. The inflammatory cascade becomes uncontrolled, damaging healthy tissues in addition to the initial insult, whether from infection, trauma, or burns.
Systemic Inflammatory Response Syndrome (SIRS) results from a dysregulated immune response, where excessive cytokine release (a cytokine storm) triggers widespread inflammation. This causes vasodilation, increased capillary permeability, and tissue edema, leading to impaired tissue perfusion and potential multi-organ dysfunction. The inflammatory cascade becomes uncontrolled, damaging healthy tissues in addition to the initial insult, whether from infection, trauma, or burns.
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