ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 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 2 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.
Question 3 of 5
A nurse is educating a client about blood cell formation in the body. The nurse documents the education and refers to blood cell formation as?
Correct Answer: B
Rationale: The correct answer is B: Hematopoiesis. Hematopoiesis is the process of blood cell formation in the body, which occurs in the bone marrow. This term specifically refers to the production of red blood cells, white blood cells, and platelets. Hepatomegaly (
A) refers to liver enlargement, osteogenesis (
C) is the process of bone formation, and splenomegaly (
D) refers to spleen enlargement. These terms are not related to blood cell formation.
Question 4 of 5
The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?
Correct Answer: B
Rationale: The correct answer is B: Radial pulses 2+ with regular rate and rhythm bilaterally. This finding indicates normal peripheral perfusion. 2+ denotes a normal, easily palpable pulse, and regular rate and rhythm indicate proper blood flow. Capillary refill <5 seconds (choice
A) is normal but is not specific to peripheral vascular assessment. Feet pale and cool (choice
C) suggest poor perfusion, while ankle edema (choice
D) indicates venous insufficiency or fluid retention, not a normal finding in a peripheral vascular assessment.
Question 5 of 5
During an assessment of the cranial nerves (CNS), the nurse finds the following asymmetry when the client smiles or frowns, uneven lifting of the eyebrows, and escape of air when the nurse presses against the right puffed cheek. The nurse recognized that these findings indicate dysfunction of which cranial nerve(s)?
Correct Answer: D
Rationale: The correct answer is D: Motor component of CN VII. These findings point to dysfunction of the facial nerve (CN VII), which controls facial expressions and muscles of the face. Uneven lifting of eyebrows, asymmetry when smiling or frowning, and escape of air when pressing on the cheek are all indicative of CN VII dysfunction. Option A is incorrect because CN X is not involved in facial expressions, and CN VII does not have a sensory component. Option B is incorrect as CN XI is responsible for shoulder movements, not facial expressions. Option C is incorrect because CN IV is the trochlear nerve, which controls eye movements.