ATI ENGAGE ADULT MEDICAL SURGICAL RN: ALTERATION IN
HEALTHCARE- RN ALTERATION IN NEUROLOGIC FUNCTION
ASSESSMENT
Question 1 of 28
Question 2 of 28
Question 3 of 28
A nurse is caring for a client who has been admitted for head trauma relating to a fall. The
client is developing cerebral edema. Which of the following types of intravenous (IV) fluid
should the nurse expect to administer to the client?
A. 0.9% Sodium Chloride (0.9% NaCl)
B. 0.45% Sodium Chloride (0.45% NaCl)
C. dextrose in Water (DIOW)
D. dextrose 5% in lactated Ringer's (D5LR)
Answer: C. dextrose in Water (DIOW)
Question 4 of 28
A nurse is caring for a 25-year-old, white, female client without housing in the intensive care
unit admitted for an aneurysm. The client's blood pressure is 118/78 mm Hg and heart rate is
88/min. Their medical history includes Type I diabetes, obesity, and arthritis. What is the
client's highest risk factor for the aneurysm to rupture?
A. Female
B. Being without housing
C. Ethnicity
D. Age
Answer: A. Female
Question 5 of 28
A nurse is caring for a client on the neurology unit admitted with a hemorrhagic stroke. The
family is asking how a haemorrhagic stroke occurs. Which of the following should the nurse
include in their response?
A. "A haemorrhagic stroke is caused by bleeding in the brain."
B. "A haemorrhagic stroke is caused by a blood clot that temporarily blocks blood flow."
C. "A haemorrhagic stroke is caused by a complete blockage of arterial blood flow in the
brain."
D. “A haemorrhagic stroke is caused by a blood clot that travelled from the leg to the brain.”
Answer: A. "A haemorrhagic stroke is caused by bleeding in the brain."
Question 6 of 28
A nurse is providing discharge teaching for a client who has been newly diagnosed with
migraine headaches. Which of the following topics are important to include in the teaching as
migraine triggers? (Select all that apply).
A. Avoid dehydration
B. Changes in weather
C. Caffeine
D. Food containing nitrates or tyramine
E. Loud noise
F. Bright lights
Answer: B. Changes in weather
C. Caffeine
D. Food containing nitrates or tyramine
F. Bright lights
Explanation:
A. Avoid dehydration is incorrect. Avoiding dehydration is not a trigger for a migraine.
B. Changes in weather is correct. Changes in weather can be a trigger for a migraine.
C. Caffeine is correct. Caffeine can be a trigger for a migraine.
D. Food containing nitrates or tyramine is correct. Foods containing nitrates or tyramine can
be triggers for a migraine.
E. Loud noise is incorrect. Loud noise is not a trigger for migraine; containing nitrates or
tyramine and bright lights can be triggers for a migraine.
F. Bright lights is correct. Bright lights can be a trigger for a migraine.
Question 7 of 28
A nurse is caring for a client with a new diagnosis of Parkinson's Disease. The nurse notices
the client has bilateral hand tremors and balance problems when walking to the bathroom.
Which of the following pathological processes are the basis of the client's clinical
manifestations?
A. There is a major decrease in dopamine-producing nerve cells of the substantia nigra.
B. The serotonin-producing nerve cells of the brain are duplicating.
C. There is demyelination of the nerve cells that control the nerve signals from the spinal
cord to the brain.
D. The aging of the nerves results in decreased and interrupted nerve transmission.
Answer: A. There is a major decrease in dopamine-producing nerve cells of the substantia
nigra.
Question 8 of 28
A client who was brought to the emergency department (ED) by a friend is reporting right
arm weakness and slurred speech, which has lasted about 2 hours. Which of the following
pieces of medical history information should the nurse expect to receive from the client?
A. History of seizure disorder
B. History of Parkinson's Disease
C. History of atrial fibrillation
D. History of meningitis
Answer: C. History of atrial fibrillation
Question 9 of 28
A nurse is providing care for a client in the emergency department (ED) who is reporting
headache, sensitivity to light, blurred vision, and nausea. Which of the following
prescriptions should the nurse expect from the provider to determine if the diagnosis is
meningitis?
A. Computed tomography (CT) of the head
B. Magnetic resonance imaging (MRI) of the brain
C. Lumbar puncture
D. Head ultrasound
Answer: C. Lumbar puncture
Question 10 of 28
A nurse is caring for a client who came to the clinic after experiencing right arm weakness for
a few hours in the morning. The provider tells the client that they experienced a transient
ischemic attack (TIA). After the provider leaves the room, the client asks, "What exactly is a
TIA?" Which of the following should the nurse include in the response? (Select all that
apply.)
A. "A TIA lasts less than 24 hours."
B. "With a TIA you don't need to go to the hospital if the weakness goes away."
C. "When you have a TIA, blood flan is temporarily blocked to the brain."
D. “A TIA is a predictor of an impending stroke.”
E. "You may have neurological dysfunction from the TIA for the rest of your life."
Answer: A. "A TIA lasts less than 24 hours."
C. "When you have a TIA, blood flan is temporarily blocked to the brain."
D. “A TIA is a predictor of an impending stroke.”
Explanation:
A. "A TIA lasts less than 24 hours" is correct. A TIA produces manifestations related to the
area of the brain in which blood flow and oxygen supply are temporarily disrupted. It may
last for only a few minutes, or up to 24 hours.
B. "With a TIA, you don't need to go to the hospital if the weakness goes away" is incorrect.
A TIA needs to be taken as a major warning sign to seek medical attention immediately.
Therefore, clients must still go to the hospital even if the signs and symptoms go away.
C. "When you have a TIA, blood flow is temporarily blocked to the brain" is correct. A TIA
produces manifestations related to the area of the brain in which blood flow and oxygen
supply are temporarily disrupted.
D. "A TIA is a predictor of an impending stroke" is correct. TIA are predictors of impending
strokes.
E. "You may have neurological dysfunction from the TIA for the rest of your life" is
incorrect. Unlike a stroke, a TIA resolves completely and does not cause residual
neurological manifestations
Question 11 of 28
A nurse is providing discharge education to an older adult client who has a cerebral
aneurysm. Which of the following pieces of information is most important to include?
A. Follow up with psychologist
B. Eliminate caffeine consumption
C. Decrease smoking
D. Identify family history of cerebral aneurysm
Answer: C. Decrease smoking
Question 12 of 28
A nurse is caring for a 36-year-old client admitted for a subdural hematoma (SDH), Which of
the following risk factors should the nurse collect additional information on? (Select all that
apply).
A. Ask whether the client is currently serving in the Army
B. Ask whether the client is receiving chemotherapy
C. Ask whether the client is participating in football
D. Ask about client's intake of alcohol
E. Assess blood pressure (BP)
Answer: A. Ask whether the client is currently serving in the Army
C. Ask whether the client is participating in football
D. Ask about client's intake of alcohol
Explanation:
A. Ask whether the client is currently serving in the Army is correct. Military service is a risk
factor for a subdural hematoma.
B. Ask whether the client is receiving chemotherapy is incorrect. Client receiving
chemotherapy is not a risk factor for a subdural hematoma.
C. Ask whether the client is participating in football is correct. Playing contact sports is a risk
factor for a subdural hematoma.
D. Ask about client's intake of alcohol is correct. Alcohol abuse is a risk factor for a subdural
hematoma.
E. Assess blood pressure (BP) is incorrect. Hypertension is not a risk factor for a subdural
hematoma.
Question 13 of 28
A 14-year-old client is brought to the emergency department (ED) by their guardian. The
guardian states that their child was playing football and was hit hard on the head about a
week ago. The client was feeling okay until a few days ago when they began having
headaches that won't go away. Which of the following types of head injury is this client
experiencing?
A. Subacute subdural hematoma
B. Acute subdural hematoma
C. Acquired brain injury
D. Penetrating head injury
Answer: A. Subacute subdural hematoma
Question 14 of 28
A nurse is planning discharge instructions for a client with chronic headaches. Which of the
following topics should the nurse plan to include in the teaching? (Select all that apply).
A. "Take your narcotic or barbiturate medication as soon as the headache begins"
B. “Be conscientious about staying hydrated”
C. "Include pickled foods in your diet"
D. "Avoid eating aged cheeses"
E. "Take your triptan medication at the beginning of the headache"
F. "Include yoga in your exercise routine"
Answer: B. “Be conscientious about staying hydrated”
D. "Avoid eating aged cheeses"
E. "Take your triptan medication at the beginning of the headache"
F. "Include yoga in your exercise routine"
Explanation:
A. "Take your narcotic or barbiturate medication as soon as the headache begins" is incorrect.
Narcotics are no longer used for headache pain. Therefore, the nurse should not plan to
include this information in the discharge instruction.
B. “Be conscientious about staying hydrated” is correct. Staying hydrated is helpful in
preventing headaches.
C. "Include pickled foods in your diet" is incorrect. Pickled foods should be avoided for
clients with chronic headaches. Therefore the nurse should not include this information in the
discharge instruction.
D. "Avoid eating aged cheeses" is correct. Aged cheeses should be avoided for clients who
have chronic headaches.
E. "Take your triptan medication at the beginning of the headache" is correct. Triptan
medications should be administered at the beginning of the headache phase.
F. "Include yoga in your exercise routine" is Correct. Yoga is helpful in preventing chronic
headaches.
Question 15 of 28
A nurse is caring for a client brought into the emergency department (ED) by ambulance. The
client's partner reports finding the client lying on the kitchen floor with jerking movements of
the whole body and urine all over the floor. Which of the following additional client findings
should the nurse expect the client's partner to report?
A. The client was staring straight ahead.
B. The client was hallucinating.
C. The client lost consciousness.
D. The client said his body was tingling.
Answer: C. The client lost consciousness.
Question 16 of 28
A nurse is caring for a client who has Parkinson's disease, who comes into the clinic every six
months for check-ups. The nurse notices the client has slower arm and leg movements and is
losing balance when walking down the hall. Which of the following stages of the disease
should the nurse document in the client's record?
A. stage 1
B. stage 2
C. Stage 3
D. Stage 4
Answer: C. Stage 3
Question 17 of 28
A nurse is discussing the discharge plan for a client with a mild concussion. Which of the
following statements by the client's partner indicates an understanding of the client's
recuperation?
A. "1 understand that my partner may have difficulty with attention and memory for up to
four weeks."
B. "1 realize that my partner will have permanent damage to the brain."
C. “I will not be concerned about blurred vision that lasts longer than three months.”
D. "It is typical for a client with mild concussion to have headaches for up to six months."
Answer: A. "1 understand that my partner may have difficulty with attention and memory for
up to four weeks."
Question 18 of 28
A nurse is providing care for four clients on a neurosurgical unit. Which of the following
clients is experiencing a generalized seizure?
A. The client sitting in a chair staring out the window with all their muscles tightened.
B. The client lying in the bed whose right leg begins to stiffen.
C. The client lying on the floor, unresponsive, with movement of the whole body.
D. The client walking in the hallway whose legs suddenly give out, causing them to fall to the
ground
Answer: C. The client lying on the floor, unresponsive, with movement of the whole body.
Question 19 of 28
A nurse is admitting a client who has peripheral neuropathy of both feet. The client has a
history of diabetes type Il and hypertension. Which of the following questions should the
nurse ask while performing the admission assessment?
A. "How are you sleeping at night?"
B. "What do you think is causing decreased sensation to your feet?"
C. How long have you had diabetes?"
D. "Are you monitoring your blood pressure every day?"
Answer: A. "How are you sleeping at night?"
Question 20 of 28
A nurse is caring for a client who has epilepsy. Which of the following potential
comorbidities should the nurse be alert to when assessing the client? (Select all that apply.)
A. Dementia
B. Anxiety
C. Inflammation of the joints
D. Depression
E. Social isolation
Answer: B. Anxiety
D. Depression
E. Social isolation
Explanation:
A. Dementia is incorrect. Dementia is not a comorbidity of epilepsy. However, depression,
anxiety, and social isolation are all potential comorbidities of epilepsy that the nurse should
evaluate the client for during assessment.
B. Anxiety is correct. Anxiety is a comorbidity of epilepsy that the nurse should evaluate the
client for during assessment.
C. Inflammation of the joints is incorrect. Joint inflammation is not a comorbidity of epilepsy.
However, depression, anxiety, and social isolation are all potential comorbidities of epilepsy
that the nurse should evaluate the client for during assessment.
D. Depression is correct. Depression is a comorbidity of epilepsy that the nurse should
evaluate the client for during assessment.
E. Social isolation is correct. Social isolation is a comorbidity of epilepsy that the nurse
should evaluate the client for during assessment.
Question 21 of 28
A nurse is caring for a client who has been recently diagnosed with a seizure disorder. The
client's partner is asking about what to do for the client during a seizure. Which of the
following should the nurse include in the response? (Select all that apply).
A. "Move everything away that could injure the client"
B. "Support the client's head to prevent head injury"
C. "Prevent the client from moving around during a seizure"
D. "Turn the client's head to the side during the seizure to prevent client from choking"
E. "Place a padded object in the client's mouth to prevent the tongue from being bitten"
F. "Loosen any clothing around the client's neck"
Answer: A. "Move everything away that could injure the client"
B. "Support the client's head to prevent head injury"
D. "Turn the client's head to the side during the seizure to prevent client from choking"
F. "Loosen any clothing around the client's neck"
Explanation:
A. "Move everything away that could injure the client" is correct. Moving everything away
that could injure the client is important to include in the nurse's response. Leaving items in
the area surrounding the client can be hazardous and could cause physical harm to the client
who is experiencing a seizure,
B. "Support the client's head to prevent head injury" is correct. Supporting the client's head to
prevent head injury is important to include in the nurse's response.
A client who is experiencing a seizure may thrash their head around, causing potential head
injury.
C. "Prevent the client from moving around during a seizure" is incorrect. Preventing the
client from moving around during a seizure is not appropriate to include in the nurse's
response. Physically restraining a client who is having a seizure can cause physical injuries
and make the client become more confused, agitated, or aggressive,
D. "Turn the client's head to the side during the seizure to prevent client from choking" is
correct. Turning the client's head to the side during the seizure to prevent client from choking
is important to include in the nurse's response.
E. "Place a padded object in the client's mouth to prevent the tongue from being bitten" is
incorrect. Placing a padded object in the clients mouth to prevent the tongue from being
bitten should not be included in the teaching. Placing a padded object in the client's mouth
during a seizure can occlude the airway or could cause damage to their jaw or teeth.
F. "Loosen any clothing around the client's neck" is correct. Loosening any clothing around
the client's neck is important to include in the nurse's response.
Question 22 of 28
A nurse is providing discharge instruction to a client who has recovered from a transient
ischemic attack (TIA). Which of the following should the nurse teach the client regarding risk
of reoccurrence of a TIA or stroke? (Select all that apply).
A. Monitor blood pressure at least daily and report elevations to the provider
B. If the client experiences anxiety, the provider should be notified
C. Decrease smoking until all manifestations of TIA are resolved
D. Report manifestations of depression to the provider
E. Avoid intake of alcohol within 90 days after discharge
Answer: A. Monitor blood pressure at least daily and report elevations to the provider
B. If the client experiences anxiety, the provider should be notified
D. Report manifestations of depression to the provider
E. Avoid intake of alcohol within 90 days after discharge
Explanation:
A. Monitor blood pressure at least daily and report elevations to the provider is correct. It is
important to keep blood pressure stable as blood pressure elevations are seen in up to 80% of
clients who experience TIA.
B. If the client experiences anxiety, the provider should be notified is Correct. Anxieo is
associated with risk of recurrent TIA.
C. Decrease smoking until all manifestations of TIA are resolved is incorrect. Clients should
stop smoking completely as clients who smoke after experiencing a TIA are at greater risk of
a stroke.
D. Report manifestations of depression to the provider is correct. psychosocial anxiety and
depression are associated with risk of recurrent TIA.
E. Avoid intake of alcohol within 90 days after discharge is correct. High alcohol intake
within 90 days after a TIA is associated with increased risk of stroke.
Question 23 of 28
A nurse is caring for a client who has a Severe migraine headache. Which of the following is
the most likely trigger for the migraine?
A. Diagnosis of meningitis
B. A newly diagnosed brain tumour
C. The client reporting intermittent fasting diet
D. The client reporting a recent fall
Answer: C. The client reporting intermittent fasting diet
Question 24 of 28
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following
clients are at risk for stroke? (Select all that apply.)
A. The client with a blood pressure of 1 80/96 mm Hg
B. The client with Type II diabetes mellitus (0M)
C. The client with heart failure
D. The client with sleep apnea
E. The client with mitral valve stenosis
Answer: A. The client with a blood pressure of 1 80/96 mm Hg
B. The client with Type II diabetes mellitus (0M)
D. The client with sleep apnea
E. The client with mitral valve stenosis
Explanation:
A. The client with a blood pressure of 180/96 mm Hg is correct. Hypertension is one of the
most common risk factors for stroke.
B. The client with Type II diabetes mellitus (DM) is correct. Diabetes is one of the most
common risk factors for disease of the small cerebral vessels which can result in stroke.
C. The client with heart failure (HF) is incorrect. Heart failure is not associated with
increased risk of stroke.
D. The client with sleep apnea is correct. Obstructive sleep apnea is a risk factor for stroke.
E. The client with mitral valve stenosis is correct. Heart valve disease is associated with
increased stroke risk.
Question 25 of 28
A nurse is caring for a client admitted to the intensive care unit (ICU) for slurred speech,
right sided weakness. and facial droop. The prescription includes seizure precautions and
tissue plasminogen activator (tPA). Which of the following types of neurological impairment
is this client most likely experiencing?
A. Transient ischemic attack (TIA)
B. Ischemic stroke
C. Haemorrhagic stroke
D. Cerebral aneurysm
Answer: B. Ischemic stroke
Question 26 of 28
A nurse is caring for a client who is having a seizure that consists of crying and laughing. The
nurse should document this as which of the following types of seizure?
A. Focal non-motor behavior arrest seizure
B. Focal non-motor emotional seizure
C. Focal atonic seizure
D. Focal automatism seizure
Answer: B. Focal non-motor emotional seizure
Question 27 of 28
A client arrives to the clinic reporting excessive sweating. The nurse reviews the client's
medical record and notes a diagnosis of peripheral artery disease, resulting in autonomic
nerve damage. Which of the following findings should the nurse expect during the
assessment? (Select all that apply).
A. Foot drop
B. Diarrhoea
C. Weak hand grasp
D. Constipation
E. Sexual dysfunction
Answer: B. Diarrhoea
D. Constipation
E. Sexual dysfunction
Explanation:
A. Foot drop is incorrect. Foot drop is a motor symptom related to peripheral neuropathy.
However, diarrhoea, constipation, and Sexual dysfunction are manifestations of autonomic
symptoms of peripheral neuropathy.
B. Diarrhoea is correct. Diarrhoea is an autonomic symptom of peripheral neuropathy and the
nurse should question the client about bowel and bladder function Weak hand grasp is
incorrect.
C. Weak hand grasp is a motor symptom related to peripheral neuropathy. However,
diarrhoea, constipation, and sexual dysfunction are manifestations of autonomic symptoms of
peripheral neuropathy.
D. Constipation is correct. Constipation is an autonomic symptom of peripheral neuropathy
and the nurse should question the client about bowel and bladder function.
E. Sexual dysfunction is correct. Sexual dysfunction is an autonomic symptom of peripheral
neuropathy and the nurse should question the client about sexual activity.
Question 28 of 28
