ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 36 Questions
Question 1 of 5
The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention?
Correct Answer: A
Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range.
Question 2 of 5
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
Correct Answer: C
Rationale: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.
Question 3 of 5
Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin 'slice' of a muscular body area?
Correct Answer: A
Rationale: A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or 'slices,' of the body. An MRI uses radiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow.
Question 4 of 5
The nurse collects data regarding a client's ability to detect sensation in the upper extremity. Which nursing action(s) is appropriate? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The nurse evaluates the extremities for sensitivity to heat, cold, touch, and pain. Various objects can be used by the nurse for this purpose, including cotton balls and tubes filled with hot or cold water. Sharp objects may be used but should not pierce the skin; therefore, it is appropriate for the nurse to stroke the client's fingers with a safety pin but not to prick the skin with a needle.
Question 5 of 5
A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:
Correct Answer: B
Rationale: Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment.