ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is taking a health history from a client. The client tells the nurse that. "It feels like the room is spinning." How should the nurse document this finding?
Correct Answer: A
Rationale: The correct answer is A: Vertigo. Vertigo is a specific sensation of spinning or movement when there is no actual movement. The term "feels like the room is spinning" is characteristic of vertigo. Seizure activity (
B) presents with abnormal electrical activity in the brain, not a sensation of spinning. Dizziness (
C) is a vague term that can encompass various sensations, not specific to spinning. Syncope (
D) refers to a temporary loss of consciousness due to decreased blood flow to the brain, not a sensation of spinning.
Question 3 of 5
The nurse is caring for a client who is concerned about sexual performance. A 70-year-old male client reported that he is concerned about declining sexual performance. The nurse is engaging in client education to explain internal causes of withdrawal from sexual activity later in life. Which of the following internal causes should the nurse discuss? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Low testosterone levels. Testosterone levels naturally decrease with age, contributing to a decline in sexual performance in older males. This decline can lead to decreased libido and erectile dysfunction. Stress (choice
A) can impact sexual performance but is not specifically related to internal causes of withdrawal from sexual activity later in life. Substance use (choice
C) can also affect sexual function but is not an internal cause. Lack of sleep (choice
D) can impact overall health and energy levels, potentially affecting sexual activity, but it is not a direct internal cause related to declining sexual performance in older males.
Therefore, the nurse should focus on discussing low testosterone levels as an internal cause of withdrawal from sexual activity later in life with the client.
Question 4 of 5
A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?
Correct Answer: D
Rationale: The correct method to assess cranial nerve II (Optic nerve) is to ask the client to read a Snellen chart. This is because cranial nerve II is responsible for vision. By asking the client to read the Snellen chart, the nurse can assess the client's visual acuity and determine if there are any issues with the optic nerve function. Listening to speech (
Choice
A) assesses cranial nerve VIII (Vestibulocochlear nerve). Identifying scented aromas (
Choice
B) assesses cranial nerve I (Olfactory nerve). Asking the client to clench their teeth (
Choice
C) assesses cranial nerve V (Trigeminal nerve).
Therefore,
Choices A, B, and C are incorrect for assessing cranial nerve II as they test different cranial nerves.
Question 5 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.