ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 of 5
A client reports pain in the left wrist after falling while playing basketball. After assessing the wrist,which of the following assessment finding would make the nurse suspect a fracture?
Correct Answer: C
Rationale: The correct answer is C: Sharp pain that increases with movement. This finding suggests a possible fracture because sharp pain that worsens with movement is characteristic of bone injury. Fractures typically cause sharp, localized pain that is aggravated by movement or pressure on the affected area. In contrast, choices A and B describe dull types of pain, which are less indicative of fractures.
Choice D mentions deep pain, which is not specific to bone injuries. The presence of sharp pain that increases with movement is a key red flag for a possible fracture, prompting further evaluation and imaging to confirm the diagnosis.
Question 2 of 5
The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?
Correct Answer: C
Rationale: The correct answer is C because eating red meat can cause the stool to appear non-tarry and black due to the breakdown of the heme in the meat during digestion. This is known as pseudomelena.
Choice A, taking an iron supplement, typically results in tarry stools.
Choice B, dry heaves, is not directly related to stool color.
Choice D, loss of appetite, is also unrelated to stool color changes. It is essential for the nurse to document this finding as normal to prevent unnecessary concern or interventions.
Question 3 of 5
An adolescent male is brought to the emergency department with complaints of excruciating pain in his left testicle. Which of the following should be the priority action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Complete an assessment and notify the emergency department physician immediately. This is the priority action because the excruciating pain in the left testicle could be indicative of a serious condition like testicular torsion, which requires urgent medical attention to prevent tissue damage and loss of the testicle. Performing a comprehensive assessment will help gather essential information for the physician to make an accurate diagnosis and provide timely treatment. Options A, C, and D are incorrect as they do not address the urgency of the situation and do not prioritize the patient's immediate medical needs.
Question 4 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 5 of 5
A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?
Correct Answer: D
Rationale: The correct answer is D: Ask them to clench their teeth. This assesses cranial nerve V, the trigeminal nerve, which controls the muscles involved in chewing. By asking the client to clench their teeth, the nurse can observe the strength and symmetry of the jaw muscles, which are innervated by this nerve. This test helps to assess the motor function of the trigeminal nerve.
Choice A, listening to the client's speech, is not related to cranial nerve V.
Choice B, asking them to read a Snellen chart, assesses cranial nerve II, the optic nerve.
Choice C, asking them to identify scented aromas, assesses cranial nerve I, the olfactory nerve.