ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 of 5
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
Correct Answer: B
Rationale:
To assess cranial nerve III (oculomotor nerve), the nurse should check the pupillary response to light. This is because cranial nerve III controls the constriction of the pupil in response to light. By shining a light into the client's eyes, the nurse can observe the pupillary response, looking for equal and brisk constriction. This assessment helps to determine the integrity of cranial nerve III function. Observing for facial symmetry (choice
A) is related to cranial nerve VII (facial nerve). Testing visual acuity (choice
C) is related to cranial nerves II (optic nerve) and V (trigeminal nerve). Eliciting the gag reflex (choice
D) is related to cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve).
Question 2 of 5
The physician comments that the client has abdominal borborygmic. The nurse recognizes that which of the following is the best description of borborygmic?
Correct Answer: D
Rationale: The correct answer is D: Loud gurgling bowel sounds. Borborygmi are loud, prolonged, high-pitched gurgling bowel sounds caused by increased gastrointestinal motility. This indicates hyperactive bowel sounds.
A: A peritoneal friction rub is a sign of peritoneal inflammation, not related to bowel sounds.
B: Loud continual humming bowel sounds do not describe borborygmi, which are gurgling sounds.
C: Hypoactive bowel sounds are decreased or absent bowel sounds, opposite of borborygmi.
Question 3 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 4 of 5
The nurse is taking a health history from a client. The client tells the nurse that. "It feels like the room is spinning." How should the nurse document this finding?
Correct Answer: A
Rationale: The correct answer is A: Vertigo. Vertigo is a specific sensation of spinning or movement when there is no actual movement. The term "feels like the room is spinning" is characteristic of vertigo. Seizure activity (
B) presents with abnormal electrical activity in the brain, not a sensation of spinning. Dizziness (
C) is a vague term that can encompass various sensations, not specific to spinning. Syncope (
D) refers to a temporary loss of consciousness due to decreased blood flow to the brain, not a sensation of spinning.
Question 5 of 5
The nurse is describing how to perform a testicular self-examination to a client. Which of the following should be the appropriate statement by the nurse?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale:
Choice B is the correct answer because it emphasizes the importance of seeking medical attention if the client notices any abnormalities during the testicular self-examination. This is crucial as early detection of testicular cancer can lead to better treatment outcomes. Calling the health care provider for an enlarged testicle or painless lump ensures prompt evaluation and appropriate management.
Summary of Incorrect
Choices:
A: Incorrect. The timing of the testicular self-examination is not as critical as seeking medical attention for any abnormalities found.
C: Incorrect. Performing a testicular examination once a week may lead to unnecessary anxiety and over-monitoring, as testicular cancer is relatively rare.
D: Incorrect. While the description of the testicle is accurate, this choice does not stress the importance of seeking medical advice for abnormalities found during the examination.