ATI NEUROSENSORY ( UPDATED 2025/2026 ) COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
1. client sustained multiple injuries related to motor vehicle crash. When monitoring for
manifestations of pneumothorax, what should nurse observefor ?: absence of breath sounds
(will have diminished/absent breath sounds on affected side due to partial/total collapse of
lung)
2. client has a cerebral aneurysm. What finding should nurse report ?: clientasks that his bed
linens be changed after an episode of urinary incontinence (urinaryincontinence indicates a loss
of reflex function, indicating ICP)
3. caring for client who sustained a basalskull fracture.Notices a thin streamof clear drainage
coming from right nostril. Priority nursing action ?: test thedrainage for glucose (because of
high risk of cerebral spinal fluid leak w/ basal skullfractures)
4. collecting data for a neurological assessment for a client receiving tx for head trauma.
What info is needed forfunction ofthe 3rd cranial nerve ?: instructthe client to look up & down
without moving his head (extraocular eye movements)
5. monitoring spinal cord injury & suspects autonomic dysreflexia.Whataction should be
implemented 1st ?: place the client in a sitting position (to decrease the symptom of
hypertension for autonomic dysreflexia)
6. client had a craniotomy 3 weeks ago & remains unconscious. While bathing client,the AP
talk to him about current events.Clients wife asks aboutAP's actions.What statement reinforces
clients wife the importance of talkingto client ?: "Clients like your husband, who are
unconscious, may still be able to her." (provides sensory stimulation & should be encouraged)
7. a family member is instructed on interventions for safe swallowing for client who has
residual effects from a stroke.Whats most important conceptfor family members to
understand ?: place the client in the upright position to facilitate swallowing (greatest risk for
client is injury from aspiration)
8. nurse is caring for client w/ a spinal cord injury at T-4. Nurse understandsthat client is at
increased risk for autonomic dysreflexia & that this physiologic reaction could be triggered by
what ?: bladder distention (autonomic dysreflexia can occur w/ spinal cord injury at/above T-6
level. A. dysreflexia happens when theresirritation, pain, or stimulus to nervous system below
level of injury. Most are relatedto bladder, bowel, & skin)
9. client is about to start using transcutaneous electrical nerve stimulation (TENS) to
manage chronic pain.Whats a statement indicating need for teaching ?: "It's unfortunate that I
have to be in the hospital for thistx." (client must attachelectrode pads to skin of choice &
should remove hair for pads)