ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 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 2 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 3 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 4 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.
Question 5 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.