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 preparing to screen a client for deep vein thrombosis (DVT). Which of the following techniques should the nurse recognize as the appropriate technique to screen for DVT?
Correct Answer: B
Rationale: The correct answer is B: measure the calf at the widest point with a tape measure. This technique is appropriate for screening DVT because measuring the calf at the widest point helps assess for swelling, a common sign of DVT. This method provides a baseline measurement that can help monitor changes in calf size, indicating potential clot formation. Measuring the circumference of the ankle (choice
A) is not as effective as the calf measurement in detecting DVT. Checking the dorsalis pedis pulse (choice
C) or compressing it (choice
D) are not relevant for screening DVT, as DVT is primarily diagnosed through imaging studies like ultrasound rather than pulse assessment.
Question 3 of 5
During an abdominal assessment,the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?
Correct Answer: C
Rationale: The correct answer is C: Appendix. Tenderness on light palpation in the right lower quadrant indicates possible inflammation of the appendix, which is a classic sign of appendicitis. The appendix is located in the right lower quadrant of the abdomen, making it the most likely organ causing the tenderness. Sigmoid (
A) is located in the left lower quadrant. Liver (
B) is located in the right upper quadrant. Gallbladder (
D) is located in the right upper quadrant.
Therefore, the appendix is the most likely organ causing the tenderness in the right lower quadrant.
Question 4 of 5
A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Abdominal distention is a common symptom of lactose intolerance due to the inability to digest lactose. Occasional diarrhea can occur as the body tries to expel undigested lactose. Flatus is also a common symptom, as undigested lactose is fermented by gut bacteria, leading to gas production. Visible peristalsis (choice
B) is not typically associated with lactose intolerance. Hypoactive bowel sounds (choice
C) are not directly related to lactose intolerance. Overall, choices A, D, and E align with the typical clinical findings of lactose intolerance.
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.