ATI-AMS ATI Adult medical surgical Exam - Set 3 - Part 1

Correct Answer: Wash your hair before the test

Washing the hair removes oils, gels, and sprays that interfere with electrode contact and distort the brain-wave recording. Clean hair lets the electrodes pick up accurate electrical signals, giving the provider a reliable tracing. Option a is incorrect because sedatives and stimulants are actually held before an electroencephalography. These drugs alter brain-wave activity, and taking one would suppress the very electrical patterns that the test is specifically designed to capture and record. Option b is incorrect because the opposite is needed here. Clients stay awake and become sleep-deprived because cranial stress raises the chance of recording abnormal discharges, such as seizure potentials, that might otherwise be missed entirely. Option d is incorrect because fasting belongs to contrast or sedation studies. An electroencephalography is noninvasive with no dye or anesthesia, so withholding food serves no purpose, and an empty stomach offers no benefit to the recording.

Correct Answer: Assist to a supine position

A post-lumbar-puncture headache comes from cerebrospinal fluid leaking through the puncture site, and lying flat relieves the pressure differential that triggers pain when upright. The supine position also helps the puncture clot and seal. Option a is incorrect because coughing raises intracranial pressure, which intensifies a cerebrospinal-fluid-leak headache rather than easing it. The client should avoid this maneuver, since gentle rest and hydration, not forceful exhalation, are what support recovery here. Option b is incorrect because withholding fluids works against the goal. Increasing oral intake helps the body replace lost cerebrospinal fluid, so limiting it would prolong the headache instead of correcting the underlying volume deficit causing the pain. Option c is incorrect because a Glasgow Coma Scale measures level of consciousness after head trauma. This client's positional headache reflects a fluid leak, not deteriorating neurologic status, so scoring consciousness mi

Correct Answer: Moderate head injury

Eye opening to voice, incoherent speech, and withdrawal from pain together produce a midrange Glasgow Coma Scale total. A score in this band indicates a moderate head injury rather than a minor or comatose presentation. Option b is incorrect because a severe head injury with coma corresponds to a very low total at the bottom of the scale. This client's responses to voice and pain place the sum well above that threshold, so the comatose range does not fit. Option c is incorrect because minor head trauma corresponds to a near-maximum total, reflecting nearly intact eye, verbal, and motor responses. Incoherent speech and only withdrawal to pain show greater impairment than that high-scoring category would allow. Option d is incorrect because imminent brain death would show no eye opening, no vocalization, and no motor response, scoring near the floor of the scale. A client who responds to voice and withdraws retains meaningful brainstem and cortical function.

Correct Answer: I am allergic to shellfish

Cerebral angiography uses iodine-based contrast dye injected into an artery, and a shellfish or iodine allergy raises the risk of a contrast reaction. The provider must know this to select a different contrast medium safely. Option a is incorrect because an antihypertensive medication is not a contraindication to angiography and does not interact with contrast dye. Continuing routine blood-pressure control poses no added procedural risk, so this detail does not require provider notification before the study. Option c is incorrect because walking to the appointment has no bearing on the safety of an arterial contrast study. This activity does not affect bleeding risk, renal clearance of dye, or allergy potential, so it warrants no special report at all. Option d is incorrect because a mild headache is a common, nonspecific complaint that does not alter angiography planning. Unlike an allergy that can trigger anaphylaxis, this symptom carries no procedural danger and needs no urgent comm

Correct Answer: I will report if pain continues

Reporting inadequate relief lets the nurse reevaluate and adjust the plan so the regimen actually controls the pain. This shows the client grasps that the pump is meant to keep them comfortable, not to be endured silently. Option b is incorrect because only the client should ever press the button. Allowing a family member to dose risks inadvertent overdose, because the client cannot self-protect by stopping once sedation begins, which is the built-in safeguard the system depends on. Option c is incorrect because waiting for severe pain undermines the purpose of the device. The client should activate it as pain begins, since small frequent doses maintain steady plasma levels and prevent pain from escalating beyond easy control later. Option d is incorrect because a lockout interval prevents a dose with every press. This preset minimum spacing blocks medication when a button push falls inside the interval, which is precisely how the pump guards the client against an overdose.

Correct Answer: Implement droplet precautions

These findings suggest bacterial meningitis, which is contagious and carries high mortality. Implementing droplet precautions first protects others from a spreadable, life-threatening infection, making it the priority before the other appropriate interventions are carried out. Option a is incorrect because intravenous access is needed for fluids and medications, yet it does nothing to contain a transmissible pathogen. The immediate threat of spread to staff and other clients outranks securing a line at this particular moment. Option c is incorrect because dimming lights eases photophobia and provides comfort, but comfort measures do not address contagion. This intervention can follow once the client is isolated and the infection is no longer free to spread to others nearby. Option d is incorrect because antibiotics treat the client and are given soon, though they take time to render secretions noninfectious. Until then the surrounding people remain exposed, so isolation must come befor

Correct Answer: Flex the neck toward the chest

With the client supine, the nurse places hands behind the neck and bends the head toward the chest. Involuntary flexion of the knees and hips in response is a positive Brudzinski's sign, indicating meningeal irritation. Option b is incorrect because flexing the hip and then extending the knee tests Kernig's sign, a different meningeal maneuver. Resistance and pain with that leg extension, not the neck-based response, are what define a positive Kernig's finding instead. Option c is incorrect because stroking the sole elicits the Babinski reflex, which evaluates upper motor neuron pathways. This plantar test has no role in screening for the meningeal irritation that a positive Brudzinski's sign is meant to reveal. Option d is incorrect because tapping the patellar tendon checks a deep tendon reflex arc at the knee. While meningitis can heighten reflexes, this maneuver does not specifically demonstrate the neck-flexion response that Brudzinski's sign actually requ

Correct Answer: Position the client side-lying

In the postictal phase the greatest danger is aspiration of secretions. Placing the client in a side-lying position keeps the airway clear and lets oral secretions drain, protecting the airway before any other intervention is started. Option a is incorrect because reorienting a confused client is supportive and calming, yet it does not protect the airway. A client recovering from a seizure can still aspirate, so positioning for drainage must come before any verbal reassurance is offered. Option b is incorrect because recording the duration and findings is essential nursing documentation, but it addresses the record rather than the client's immediate physical safety. Airway protection through correct positioning takes clear priority over completing the chart at this point. Option d is incorrect because offering fluids to a postictal client who is still confused risks choking, because swallowing and alertness have not fully returned yet. Hydration can wait until the client is awake

Correct Answer: I will take it daily on schedule

Taking phenytoin at the same time daily maintains a steady therapeutic blood level, which is essential for consistent seizure control. Stable timing prevents the peaks and troughs that could either trigger seizures or cause drug toxicity. Option a is incorrect because phenytoin does not cause significant gastrointestinal upset requiring an antacid, and antacids can interfere with its absorption. Routinely adding one is unnecessary and could reduce the amount of drug that the client actually receives. Option c is incorrect because therapeutic phenytoin levels are checked by blood tests, not urine tests. Blood sampling reflects the circulating drug concentration that determines effectiveness and safety, which a urine analysis simply cannot measure with the needed accuracy. Option d is incorrect because phenytoin causes gum overgrowth, not gum recession. The client should expect gingival enlargement and respond with diligent oral hygiene and regular dental visits, which is the opposite of

Correct Answer: Use home oxygen while sitting upright

Home oxygen at the start of a cluster headache can relieve the pain within minutes. The client should remain sitting while using it and follow home oxygen safety precautions, making this an effective intervention at attack onset. Option a is incorrect because lying flat does not target cluster headache pain, and the recommended approach keeps the head elevated with oxygen instead. Pressing on the temples offers no proven relief for this intense, unilateral pain pattern the client experiences. Option b is incorrect because caffeine is a recognized headache trigger to limit, not a remedy to consume during an attack. Drinking it could worsen the symptoms rather than abort the episode that the client is actively trying to control here. Option c is incorrect because increased physical activity aggravates head pain rather than relieving it. Vigorous exercise during an attack would worsen the severe pain, which is the opposite of the rest and oxygen the client genuinely needs at onset.

Correct Answer: Pill-rolling tremor of the fingers

A pill-rolling tremor of the fingers is a cardinal sign of Parkinson's disease, arising from basal ganglia overstimulation by acetylcholine. It accompanies rigidity, bradykinesia, and postural instability as the hallmark motor features of the disorder. Option b is incorrect because bilateral ankle edema is not a primary feature of the disease, and when it appears it usually reflects a medication effect rather than the disorder itself. The expected motor signs involve tremor and rigidity, not swelling. Option c is incorrect because loss of central vision points to macular degeneration of the eye, an unrelated condition. Parkinson's disease disrupts movement and posture through dopamine deficiency, not the retinal pathways that govern sharp central sight and detail. Option d is incorrect because bradykinesia means slowed and diminished movement, which is the reverse of hyperactive motion. The shuffling gait and masklike face of this disease reflect too little controlled movemen

Correct Answer: Provide a walker for ambulation

By this stage, movement slows significantly and postural instability emerges, so a walker supports safe ambulation and reduces fall risk. This assistive device matches the gait disturbance that is characteristic of this point in the disease. Option a is incorrect because urging the client to walk faster worsens the propulsive, shuffling gait and increases the likelihood of falling. Clients should instead be taught to pause periodically while walking to slow their pace, rather than to accelerate it. Option b is incorrect because active range of motion is preferred to keep the client engaged and to maintain strength. Limiting movement to passive exercises alone surrenders function that the client can still perform independently at this stage of illness. Option d is incorrect because high-calorie, high-protein supplements are recommended to counter weight loss and chewing difficulty. A low-protein product works against the nutritional goal, depriving the client of the calories and buildin

Correct Answer: Move the client near the nurses' station

A client with Alzheimer's may not remember to call for assistance, so placing them close to the nurses' station allows continuous observation. This proximity provides the ongoing supervision needed to prevent falls in a forgetful, disoriented client. Option a is incorrect because reminding the client to use a call light fails, because cognitive decline prevents reliably remembering or initiating that step. Counting on memory in a disoriented client offers no dependable protection against the next fall that may occur. Option b is incorrect because a gait belt assists with individual transfers but does nothing between them, when unsupervised wandering causes most falls. Continuous visibility addresses the broader risk that a belt used only during transfers simply cannot cover by itself. Option c is incorrect because a single-day calendar aids reality orientation in earlier stages, yet it does not stop a client from falling. Orientation tools support cognition but lack the direc

Correct Answer: Involuntary eye movements and ataxia

Multiple sclerosis destroys myelin in the brain and spinal cord, producing nystagmus, ataxia, and areas of paresthesia. These findings reflect interrupted nerve-impulse flow along demyelinated axons, which is the central mechanism of the disease. Option a is incorrect because increased salivation with swallowing difficulty points toward amyotrophic lateral sclerosis rather than multiple sclerosis. While this disease can cause dysphagia, excessive drooling is not its expected hallmark and suggests a different motor neuron process instead. Option c is incorrect because bilateral eyelid drooping characterizes myasthenia gravis, where neuromuscular transmission fails. Multiple sclerosis produces visual disturbances like diplopia and scotomas through optic nerve demyelination, not the ptosis that is typical of that other disorder. Option d is incorrect because alopecia is not a manifestation of multiple sclerosis, which spares the hair follicles. The disease attacks central nervous system m

Correct Answer: This will ease my muscle spasms

Baclofen is an antispasmodic that relieves the muscle spasticity common in multiple sclerosis. The client correctly identifies its purpose, and they should also know it can cause drowsiness and dizziness, which pose a safety concern. Option a is incorrect because baclofen must never be stopped abruptly, because sudden discontinuation can cause withdrawal effects. Improvement in symptoms does not justify halting the drug on one's own, since the medication requires a gradual, provider-guided taper to discontinue safely. Option b is incorrect because tremors in multiple sclerosis are treated with propranolol and clonazepam, not baclofen. This client has confused the spasticity benefit of baclofen with the tremor management that an entirely different drug combination is meant to provide here. Option c is incorrect because easy bruising is an effect associated with prednisone, a corticosteroid, rather than baclofen. Attributing this skin finding to an antispasmodic reflects a mix-up wi

Correct Answer: I will rise slowly from sitting

Bromocriptine is a dopamine agonist that can cause orthostatic hypotension. Rising slowly from sitting or lying lets the blood pressure adjust and prevents the dizziness and falls that a sudden change in position could trigger. Option a is incorrect because dark urine is a harmless effect of entacapone, a different Parkinson's medication, not bromocriptine. The client has matched the wrong drug to this finding, since this color change does not occur with a dopamine agonist at all. Option b is incorrect because tyramine avoidance applies to selegiline, an inhibitor that can provoke a hypertensive crisis when combined with tyramine-rich foods. Bromocriptine does not carry this dietary restriction, so the statement names a precaution meant for another drug. Option d is incorrect because skin discoloration is linked to amantadine, an antiviral used in Parkinson's, and it subsides when that drug is stopped. Bromocriptine is not the cause, so this particular concern belongs to a di

Correct Answer: This tumor will not spread elsewhere

A benign brain tumor develops from the meninges or cranial nerves, has distinct boundaries, and does not metastasize. It stays limited to brain tissue, causing harm by pressure rather than by spreading to other areas of the body. Option a is incorrect because benign tumors do not metastasize, so they do not travel to distant organs like the lungs or liver. That pattern of distant spread describes malignant disease, not the contained, well-bordered growth that this client actually has at present. Option b is incorrect because a tumor arriving from cancer elsewhere is a secondary, metastatic lesion, which is malignant by definition. A benign primary brain tumor originates within the cranial structures and is not seeded from another site somewhere else in the body. Option c is incorrect because the blood-brain barrier can block chemotherapy from reaching brain tumors in adequate doses, so the drug does not pass easily. This statement misrepresents both the tumor's nature and how medi

Correct Answer: Morphine for pain

Morphine is a central nervous system depressant that can cause respiratory depression and mask changes in level of consciousness. Given this client's slowed, shallow breathing, the nurse should clarify the order to protect ventilation and neurologic assessment. Option b is incorrect because dexamethasone reduces cerebral edema and has no central nervous system depressant effect on breathing. It supports recovery by relieving swelling, so administering it does not threaten the client's already compromised respiratory status in this situation at all. Option c is incorrect because ondansetron controls nausea and vomiting without depressing respiration or consciousness. Because it does not act on the central drive to breathe, this order poses no conflict with the client's slowed breathing pattern and may proceed safely. Option d is incorrect because phenytoin prevents seizures, a recognized post-craniotomy risk, and does not cause respiratory depression. Withholding seizure

Correct Answer: This reduces swelling around my tumor

Dexamethasone is a corticosteroid that reduces cerebral edema, which relieves headache and improves the level of consciousness. The client correctly understands it targets the swelling around the tumor rather than treating the tumor itself. Option a is incorrect because dexamethasone does not affect tumor growth or size, since it only controls the edema surrounding the lesion. Expecting it to shrink the tumor confuses symptom management with antineoplastic treatment, which this particular medication simply does not provide to the client. Option b is incorrect because corticosteroids cause hyperglycemia, raising blood sugar rather than lowering it. A client anticipating hypoglycemia has the effect backward and could miss the elevated glucose that this medication is well known to produce during therapy. Option d is incorrect because dexamethasone commonly causes weight gain and fluid retention, not weight loss. The client expecting to lose weight has reversed a key adverse effect and sho

Correct Answer: Have the client stand with eyes closed

A Romberg sign is assessed by having the client stand erect with the eyes closed. Loss of balance under these conditions is a positive result, reflecting impaired proprioceptive or cerebellar control of upright posture and steadiness. Option a is incorrect because stroking the sole of the foot tests the Babinski sign, which evaluates corticospinal tract function. This plantar maneuver assesses a reflex pathway, not the standing-balance response that defines a Romberg test performed with the eyes closed. Option c is incorrect because watching for facial drooping screens cranial nerve function, particularly the facial nerve. This observation does not measure postural stability, so it cannot demonstrate the balance loss that a positive Romberg sign is specifically meant to reveal. Option d is incorrect because checking the blink response evaluates cranial nerve integrity rather than equilibrium. Rapid blinking has no role in assessing the proprioceptive balance that the Romberg maneuver,