2021 ATI Medical/Surgical Neurosensory AH1 with Answers (80 Solved Questions)

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ATI Medical/Surgical Neurosensory AH110/27/21A nurse is collecting data from a client who has a brain tumor. Which of the following indicates cranial nerve involvement?A. DysphagiaB. Positive Babinski signC. Decreased deep-tendon reflexesD. AtaxiaRationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X(vagus). A positive Babinski sign, or the turning up of the toes upon plantar stimulation, is associated with an upper motorneuron lesion. The cranial nerves primarily innervate the face, neck, and a few organs. Decreased deep-tendon reflexesindicate impairment in the electrical conduction of spinal nerves that interfere with reflex arcs. The cranial nerves primarilyinnervate the face, neck, and a few organs. Ataxia, or uncoordinated movements of the extremities, can indicate damage tothe cerebellum or motor pathways. The cranial nerves primarily innervate the face, neck, and a few organs.A nurse in a acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following suppliesshould the nurse place on the client's bedside?A. Metered-dose inhalerB. Continuous passive motion machineC. External defibrillator padsD. Oral-nasal suction equipmentRationale: The client who has myasthenia gravis is at risk for aspiration because of progressive weakness of the oropharyngealmuscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors.The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratorydistress. External defibrillator pads are used for a client who has a cardiac dysrhythmia; however, they are not indicated for aclient who has myasthenia gravis. A continuous passive motion machine is used to provide continuous motion of a joint for aclient who is postoperative following joint surgery; however, it is not indicated for a client who has myasthenia gravis. Ametered-dose inhaler is used to administer medications for a client who has asthma; however, it is not indicated for a clientwho has myasthenia gravis.A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurseexpect?A. Tonic-Clonic seizuresB. Report of a severe headacheC. Weakness of the lower extremitiesD. Decreased level of consciousnessRationale: Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorderof the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lowerextremities, and can advance to the upper extremities. Guillain-Barré syndrome is an inflammatory disorder of the peripheralnerves. Decreased level of consciousness is not a manifestation of Guillain-Barré syndrome. Guillain-Barré syndrome is aninflammatory disorder of the peripheral nerves. Severe headaches are not a manifestation of Guillain-Barré syndrome.Guillain-Barré syndrome is an inflammatory disorder of the peripheral nerves. Tonic-clonic seizures are not a manifestation ofGuillain-Barré syndrome.A nurse is collecting data from a client who has a high-thoracic spinal cord injury. The nurse should identify which of thefollowing findings as a manifestation of autonomic dysreflexia?A. Flushing of the lower extremitiesB. HypotensionC. TachycardiaD. Report of a headacheRationale: Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a cervical or thoracic spinal cordinjury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestationsinclude a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension. Autonomicdysreflexia is a neurologic emergency that occurs in clients who have a cervical or thoracic spinal cord injury above the level ofT6. Manifestations include bradycardia but not tachycardia. Autonomic dysreflexia is a neurologic emergency that occurs inclients who have a cervical or thoracic spinal cord injury above the level of T6. Manifestations include hypertension but not

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