ATI RN
ATI RN Fundamentals Exam 2 Questions
Extract:
Question 1 of 5
A nurse documents that the client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?
Correct Answer: D
Rationale: The pupillary light reflex involves both pupils constricting in response to bright light to protect the retina. Convergence is a different reflex, focusing is unrelated to pupil size, and dilation in bright light is abnormal. No Light, Normal Response to Light, Positive RAPD of Right Eye, Stanford Medicine 25
Question 2 of 5
A client comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The client also complains of dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this client has manifestations of:
Correct Answer: A
Rationale: The symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and pain in the cheeks and teeth suggest maxillary sinusitis, an inflammation of the maxillary sinuses. Nasal polyps cause congestion, frontal sinusitis causes forehead pain, and posterior epistaxis involves nosebleeds, not these symptoms.
Question 3 of 5
The nurse is caring for an older adult client who has recently had a stroke. The nurse assesses that the right side of the client's face is drooping. The nurse might also expect which of the following assessment findings?
Correct Answer: C
Rationale: Dysphagia, or difficulty swallowing, is commonly associated with stroke due to muscle weakness, including facial muscles. Facial drooping on one side, as seen in this client, indicates neurological impairment that can affect swallowing muscles. Xerostomia (dry mouth), epistaxis (nosebleed), and rhinorrhea (runny nose) are not directly related to stroke-induced facial drooping.
Question 4 of 5
A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?
Correct Answer: C
Rationale: Placing the arm above heart level can falsely lower the blood pressure reading. The arm should be at heart level. Checking the gauge, centering the cuff, and wrapping it firmly are correct actions.
Question 5 of 5
Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)
Correct Answer: A,B,C,D,E
Rationale: All options indicate potential respiratory or cardiovascular issues. Use of accessory muscles suggests respiratory distress. Nail bed clubbing (greater than 160 degrees) may indicate chronic hypoxia. Circumoral cyanosis reflects inadequate oxygenation. Pursed lip breathing can indicate respiratory difficulty, and a 1:1 anteroposterior-to-transverse diameter (barrel chest) is associated with COPD. All findings warrant reporting for further evaluation.