ATI Questions And Answers Neuro 2025-2026 Latest Update
Black Tag
The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be
allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and
indicate severely increased ICP. In a mass casualty situation, the overall goal is to provide lifesaving
treatment to the greatest number of people possible. - ANS-A nurse is triaging clients during a mass
casualty event. Which of the following labels should the nurse assign to a client who has a head injury with
fixed, dilated pupils?
A. Red Tag
B. Yellow Tag
C. Green Tag
D. Black Tag
A. Cerebellar dysfunction
Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive
Romberg sign. - ANS-A nurse asks a client to stand with her feet together and her eyes open. After a few
seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret
this finding as a positive Romberg test, indicating which of the following alterations?
A. Cerebellar dysfunction
B. Occipital lobe dysfunction
C. Increased intraocular pressure
D. Macular degeneration
C. Rigid skull containing cranial contents
The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and
bleeding from the head injury against the rigid skull results in an increase in ICP. - ANS-A nurse is caring
for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure
(ICP). This increase in ICP is due to which of the following?
A. Decreased cerebral perfusion
B. Leakage of cerebral spinal fluid
C. Rigid skull containing cranial contents
D. Brain herniated into the brainstem
C. The client is unable to understand words or sentences she hears.
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