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
During a community screening event for bone density an elderly client asked the nurse why she is an inch shorter in height. Which of the following responses by the nurse is correct?
Correct Answer: C
Rationale:
Correct
Answer: C
Rationale: With aging, the cartilage between the bones in the spine gets worn down, leading to decreased height. This process is known as degenerative disc disease, where the intervertebral discs lose water content and become thinner, causing a reduction in height. As a result, the individual appears shorter. This explanation directly addresses the client's concern about the loss of height and the role of cartilage degeneration in this process.
Summary:
A: Subcutaneous fat loss does not directly contribute to decreased height.
B: Spinal flexibility may decrease with age but does not specifically account for reduced height.
D: Thickening of intervertebral discs and pressure breakdown do not lead to decreased height.
Therefore, option C is the most appropriate response as it accurately explains the mechanism behind the client's height loss.
Question 3 of 5
The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA). Which of the following findings should the nurse report to the practitioner immediately?
Correct Answer: D
Rationale: The correct answer is D: Glasgow coma scale of 5. A GCS of 5 indicates severe neurological impairment requiring immediate attention. It suggests significant brain dysfunction and potential life-threatening issues. Reporting this finding promptly is crucial for timely intervention.
Choice A is incorrect as it relates to swallowing function, which is not an immediate concern.
Choice B, mild headache, is a common symptom post-MVA and does not indicate a critical issue.
Choice C, weakness, is nonspecific and does not necessarily require immediate reporting. A GCS of 5 trumps all other findings due to its severe implications.
Question 4 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.
Question 5 of 5
The nurse is assessing a client who reports an abnormal sensation of burning or tingling in extremities. Which of the following should the nurse document in the client's record?
Correct Answer: D
Rationale: The correct answer is D: paresthesia. Paresthesia refers to abnormal sensations like burning or tingling in the extremities, which the client is experiencing. A: paralysis is the inability to move or feel a body part, not related to the client's symptom. B: hemiparesis is weakness on one side of the body, not indicative of the client's reported sensation. C: paraphasia is a language disorder, not relevant to the client's complaint.
Therefore, only paresthesia accurately describes the abnormal sensation reported by the client.