ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Question 1 of 5
The nurse is performing a neurological assessment on a client with a history of Diabetes. When testing the ability to feel the vibrations of a tuning fork, the nurse notices that the client is unable to feel vibrations on the great toe or ankle bilaterally, but is able to feel vibrations on both patellae. What should the nurse suspect from these assessments?
Correct Answer: B
Rationale: The correct answer is B: Peripheral neuropathy. In Diabetes, peripheral neuropathy is a common complication affecting sensory nerves, leading to decreased ability to feel sensations like vibrations. In this case, the client's inability to feel vibrations on the great toe and ankle bilaterally but being able to feel them on the patellae indicates a distal sensory neuropathy affecting the lower extremities. Hyperalgesia (
A) is increased sensitivity to pain, not related to vibration sensation. Hyperparalysis (
C) is not a recognized medical term. Lesion of the sensory cortex (
D) would present with more widespread sensory deficits rather than a specific pattern like in peripheral neuropathy.
Question 2 of 5
The nurse is assessing a client who reports an abnormal sensation of burning or tingling in extremities. Which of the following should the nurse document in the client's record?
Correct Answer: D
Rationale: The correct answer is D: paresthesia. Paresthesia refers to abnormal sensations like burning or tingling in the extremities, which the client is experiencing. A: paralysis is the inability to move or feel a body part, not related to the client's symptom. B: hemiparesis is weakness on one side of the body, not indicative of the client's reported sensation. C: paraphasia is a language disorder, not relevant to the client's complaint.
Therefore, only paresthesia accurately describes the abnormal sensation reported by the client.
Question 3 of 5
A client comes to the clinic and reports having weakness in the left arm and leg for the past week. The nurse should perform which type of neurological exam?
Correct Answer: B
Rationale: The correct answer is B: Complete neurological examination. This is the most appropriate choice given the client's symptoms of weakness in the left arm and leg. A complete neurological examination involves assessing cranial nerves, motor function, sensory function, reflexes, coordination, and gait. This will help the nurse identify any underlying neurological issues causing the weakness. The other choices are incorrect because: A: Glasgow Coma Scale assesses level of consciousness, not weakness in limbs. C: Muscular examination focuses on muscle strength and tone, not a comprehensive neurological assessment. D: Neurologic recheck examination is not specific and does not provide a comprehensive assessment for new symptoms.
Question 4 of 5
The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA). Which of the following findings should the nurse report to the practitioner immediately?
Correct Answer: D
Rationale: The correct answer is D: Glasgow coma scale of 5. A GCS of 5 indicates severe neurological impairment requiring immediate attention. It suggests significant brain dysfunction and potential life-threatening issues. Reporting this finding promptly is crucial for timely intervention.
Choice A is incorrect as it relates to swallowing function, which is not an immediate concern.
Choice B, mild headache, is a common symptom post-MVA and does not indicate a critical issue.
Choice C, weakness, is nonspecific and does not necessarily require immediate reporting. A GCS of 5 trumps all other findings due to its severe implications.
Question 5 of 5
A nurse is caring for a client with severe bilateral lower extremity edema. The client drove self to the Emergency Department. Stated, "My legs are swollen like balloons and I can hardly walk." The client has bilateral 4+ pitting edema from feet to knees. The nurse is preparing to assess the client's medical history. Which of the following should the nurse recognize to be the underlying cause of lower extremity edema?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. Severe bilateral lower extremity edema is a common manifestation of heart failure due to the inefficient pumping of the heart leading to fluid buildup in the body. This results in increased pressure in the veins, causing fluid to leak into the surrounding tissues, leading to edema. Other choices are incorrect because excess fluid retention and consumption do not address the underlying cause of heart failure. Pulmonary embolism is a condition where a blood clot blocks the pulmonary artery, leading to symptoms such as sudden shortness of breath and chest pain, but it is not the primary cause of lower extremity edema in this scenario.