ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 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 2 of 5
The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?
Correct Answer: A
Rationale: The correct answer is A. Upon finding a firm, irregularly shaped mass during a rectal examination, the nurse should report the finding and refer the client to a specialist for further examination. This is crucial because the mass may indicate a serious underlying condition such as colorectal cancer that requires prompt evaluation. By referring the client to a specialist, the nurse ensures that the client receives appropriate diagnostic tests and timely treatment if needed. The other choices are incorrect because telling the client not to worry (
B) could lead to delayed diagnosis and treatment, asking the client to return in a month (
C) could allow the condition to progress further, and continuing the examination and documenting the findings (
D) without further evaluation by a specialist may lead to a missed diagnosis and potential harm to the client.
Question 3 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 4 of 5
The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Recognizes this dullness as indicative of an enlarged liver and refers the client to a provider. This answer is correct because dullness above the right costal margin can indicate hepatomegaly (enlarged liver), which may be due to various conditions like liver disease or infection. Referring the client to a healthcare provider is essential for further evaluation and appropriate management.
Choice B is incorrect because simply documenting the presence of hepatomegaly without further action could delay necessary medical intervention.
Choice C is incorrect as asking about alcohol intake alone may not provide a comprehensive assessment of the client's condition.
Choice D is incorrect because dullness above the right costal margin is not a normal finding and should not be overlooked.
Question 5 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.