ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client with severe bilateral lower extremity edema. The client drove self to the Emergency Department. Stated, "My legs are swollen like balloons and I can hardly walk." The client has bilateral 4+ pitting edema from feet to knees. The nurse is preparing to assess the client's medical history. Which of the following should the nurse recognize to be the underlying cause of lower extremity edema?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. Severe bilateral lower extremity edema is a common manifestation of heart failure due to the inefficient pumping of the heart leading to fluid buildup in the body. This results in increased pressure in the veins, causing fluid to leak into the surrounding tissues, leading to edema. Other choices are incorrect because excess fluid retention and consumption do not address the underlying cause of heart failure. Pulmonary embolism is a condition where a blood clot blocks the pulmonary artery, leading to symptoms such as sudden shortness of breath and chest pain, but it is not the primary cause of lower extremity edema in this scenario.
Question 2 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 3 of 5
The nurse is teaching a male client about the reproductive system. The nurse recognizes that which structure secretes a thin milky alkaline fluid to enhance the viability of sperm?
Correct Answer: A
Rationale: The correct answer is A: Cowper gland. The Cowper gland, also known as the bulbourethral gland, secretes a thin milky alkaline fluid that helps to neutralize the acidity of the urethra and enhance the viability of sperm. This fluid also lubricates the urethra, aiding in the passage of sperm during ejaculation. The other choices are incorrect because the prostate gland mainly produces a milky alkaline fluid to nourish and protect sperm, while the median sulcus is a groove on the surface of the prostate. The Cowper gland is the specific structure responsible for secreting the described fluid, making it the correct choice in this scenario.
Question 4 of 5
A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?
Correct Answer: D
Rationale: The correct method to assess cranial nerve II (Optic nerve) is to ask the client to read a Snellen chart. This is because cranial nerve II is responsible for vision. By asking the client to read the Snellen chart, the nurse can assess the client's visual acuity and determine if there are any issues with the optic nerve function. Listening to speech (
Choice
A) assesses cranial nerve VIII (Vestibulocochlear nerve). Identifying scented aromas (
Choice
B) assesses cranial nerve I (Olfactory nerve). Asking the client to clench their teeth (
Choice
C) assesses cranial nerve V (Trigeminal nerve).
Therefore,
Choices A, B, and C are incorrect for assessing cranial nerve II as they test different cranial nerves.
Question 5 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.