ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 of 5
A client drove himself to the urgent care center for, "Legs that look like balloons and difficulty walking." The nurse assesses 4+ edema of both legs based upon which finding?
Correct Answer: A
Rationale: The correct answer is A because the description of "very deep pitting indentation of legs that lasts several minutes" indicates severe edema. This level of pitting edema is associated with a significant accumulation of fluid in the tissues, causing the legs to swell like balloons. The nurse should be concerned about potential serious underlying conditions such as heart failure, kidney disease, or venous insufficiency.
Choice B is incorrect as deep pitting that lasts only a few minutes is less severe than the described scenario.
Choice C is incorrect because mild pitting with no perceptible swelling does not match the client's presentation.
Choice D is incorrect as moderate pitting that subsides rapidly is less severe than what the client is experiencing.
Question 2 of 5
The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?
Correct Answer: B
Rationale: The correct answer is B: Radial pulses 2+ with regular rate and rhythm bilaterally. This finding indicates normal peripheral perfusion. 2+ denotes a normal, easily palpable pulse, and regular rate and rhythm indicate proper blood flow. Capillary refill <5 seconds (choice
A) is normal but is not specific to peripheral vascular assessment. Feet pale and cool (choice
C) suggest poor perfusion, while ankle edema (choice
D) indicates venous insufficiency or fluid retention, not a normal finding in a peripheral vascular assessment.
Question 3 of 5
The nurse is assessing a client who reports cessation of menses. The nurse should document the cessation of menses in the client's record as:
Correct Answer: D
Rationale: The correct answer is D: menopause. Menopause is the natural process where a woman's menstrual periods stop permanently due to aging. Cessation of menses is a key characteristic of menopause. Salpingitis (
A) is inflammation of the fallopian tubes, adnexa (
B) refers to the accessory structures of the uterus, and menarche (
C) is the onset of menstruation in a young girl.
Therefore, these choices are incorrect as they do not relate to the cessation of menses.
Question 4 of 5
A client diagnosed with osteoporosis asks the nurse. "What is osteoporosis?" The nurse should provide which of the following explanations about osteoporosis?
Correct Answer: A
Rationale: The correct answer is A: It is loss of bone density.
Rationale:
1. Osteoporosis is characterized by a decrease in bone density, leading to weakened bones.
2. This loss of bone density increases the risk of fractures and bone breaks.
3. Other choices are incorrect:
- B: Osteoporosis is not about new bone growth; it is about the weakening of existing bone.
- C: Inadequate calcium intake can contribute to osteoporosis but is not the sole cause.
- D: While menopausal women are at higher risk, osteoporosis can affect men and women of all ages.
Question 5 of 5
A client states,I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness. Which of the following should the nurse expect as an assessment finding?
Correct Answer: B
Rationale: The correct answer is B: Crepitation. Crepitation refers to the crunching or grating sound heard when bones rub against each other due to cartilage wear. It is associated with osteoarthritis, which causes pain and stiffness, especially in the morning. Other choices are incorrect because:
A) Bone spur is a bony projection, not associated with sounds;
C) Tendonitis involves inflammation of tendons, not bones;
D) Fluid in the knee joint (effusion) can cause swelling but not the described symptoms.