ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
Before administering a food feeding the nurse knows to perform which of the following assessments/
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.
Question 2 of 5
The majority of lumbar disc herniations occur at the level of:
Correct Answer: B
Rationale: The correct answer is B: L4-L5. This is because the L4-L5 intervertebral disc segment experiences the highest amount of mechanical stress and mobility in the lumbar spine, making it more prone to herniation. Additionally, nerve roots at this level innervate the lower extremities, making it a common site for symptoms such as sciatica. Choices A, C, and D are incorrect because herniations at those levels are less common due to lower mechanical stress and mobility compared to L4-L5.
Question 3 of 5
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.
Question 4 of 5
The nurse will assess a loss of ability in which of the following areas?
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate neurological, musculoskeletal, or sensory issues affecting mobility. Speech (B) is related to communication, judgment (C) to decision-making, and endurance (D) to stamina, not specifically to loss of ability. Balance is crucial for mobility and overall function, making it a priority area for assessment in healthcare settings.
Question 5 of 5
The neurologist tests the 4th and 6th cranial nerves together by having a patient do which of the following?
Correct Answer: D
Rationale: The correct answer is D because testing the 4th (trochlear) and 6th (abducens) cranial nerves involves assessing eye movements. The trochlear nerve controls downward and inward eye movement, while the abducens nerve controls lateral eye movement. Asking the patient to follow the finger with their eyes tests the function of both nerves simultaneously. Choices A, B, and C do not specifically target the 4th and 6th cranial nerves, making them incorrect options.