ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 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 2 of 5
The student nurse is studying the functioning of the nervous system. Which of the following descriptions of the central nervous system is accurate?
Correct Answer: C
Rationale: The correct answer is C: The central nervous system is made up of the brain and spinal cord. This is accurate because the central nervous system comprises the brain, which controls cognitive and sensory functions, and the spinal cord, which transmits signals between the brain and the rest of the body. The other choices are incorrect because A incorrectly includes "electrical impulse stimulators," which is not a component of the central nervous system. B is incorrect as the hypothalamus and cerebral nerves are specific structures within the brain and not the entire central nervous system. D is incorrect as it confuses the central nervous system with the broader nervous system, which includes the peripheral and autonomic components.
Question 3 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 4 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.
Question 5 of 5
The nurse is preparing to complete a muscle strength assessment on a client. Which of the following assessment techniques should the nurse utilize?
Correct Answer: C
Rationale: The correct answer is C. Applying an opposing force when the individual puts a joint in flexion or extension is the appropriate technique for assessing muscle strength. This technique allows the nurse to evaluate the strength of the muscles by resisting the movement initiated by the client, providing a more accurate assessment of muscle strength. Estimating the degree of flexion and extension in each joint (choice
A) does not directly assess muscle strength. Measuring the degree of force to overcome joint flexion or extension (choice
B) focuses on the resistance rather than muscle strength. Observing muscles for contraction when lifting a heavy object (choice
D) assesses muscle function in a specific scenario, not overall strength.