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
The nurse is performing a physical assessment of the client's mandible and temporal bone. The nurse recognizes that the articulation of the mandible and the temporal bone is called?
Correct Answer: C
Rationale: The correct answer is C: Temporomandibular joint (TMJ). The TMJ is the articulation point between the mandible and the temporal bone. It allows for movements like opening and closing the mouth.
Choice A, Condyle of the mandible, is part of the mandible, not the joint itself.
Choice B, Zygomatic arch of the temporal bone, is not the site of articulation between the mandible and temporal bone.
Choice D, Intervertebral foramen, is not related to the mandible or temporal bone articulation.
Question 3 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 4 of 5
The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?
Correct Answer: D
Rationale: The correct answer is D because Cranial Nerve XI, also known as the spinal accessory nerve, innervates the sternocleidomastoid and trapezius muscles responsible for head and shoulder movements. Testing this nerve involves asking the client to move their head and shoulders against resistance, and if Cranial Nerve XI is intact, the client should be able to do this with equal strength on both sides. This response indicates proper nerve function.
Choice A is incorrect as it describes testing Cranial Nerve XII (Hypoglossal nerve) related to tongue movement.
Choice B is incorrect as it describes testing Cranial Nerve III (Oculomotor nerve) related to eye movements.
Choice C is incorrect as it describes testing Cranial Nerve VIII (Vestibulocochlear nerve) related to hearing.
Question 5 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.