ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 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 2 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 3 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.
Question 4 of 5
During an abdominal assessment,the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?
Correct Answer: D
Rationale: The correct answer is D: 5 minutes in each quadrant. It is important to listen for at least 5 minutes in each quadrant during an abdominal assessment to accurately assess for bowel sounds. Bowel sounds can be subtle and may take time to detect, especially if the client has gastrointestinal issues or is on medications that affect bowel motility. Listening for a longer duration increases the likelihood of hearing any present bowel sounds. Option A (1 minute in the center of the abdomen) is too brief and may not capture bowel sounds in all quadrants. Option B (10 minutes in each quadrant) is excessive and not necessary for a routine assessment. Option C (1 minute in each quadrant) may not be sufficient to detect bowel sounds, especially if they are diminished. Listening for 5 minutes in each quadrant allows for a thorough assessment without being overly time-consuming.
Question 5 of 5
A client tells the nurse about being very unsteady and has difficulty in maintaining balance. The nurses recognize which area of the brain is involved and require further assessment.
Correct Answer: B
Rationale: The correct answer is B: Cerebellum. The cerebellum is responsible for coordinating voluntary movements, maintaining balance, and posture. Symptoms of being unsteady and difficulty maintaining balance indicate dysfunction in the cerebellum. The brainstem (
A) is involved in basic life functions like breathing and heart rate. The extrapyramidal tract (
C) is responsible for involuntary movements. The thalamus (
D) is a relay station for sensory information. In this scenario, the symptoms point towards cerebellar dysfunction, making it the area that requires further assessment.