ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 of 5
The nurse is performing a scrotal assessment on a male client. Which of the following findings of the scrotum should the nurse recognize as abnormal?
Correct Answer: D
Rationale: The correct answer is D: Presence of small, firm, non-tender, yellowish nodules. This finding is abnormal as it could indicate the presence of testicular cancer or other concerning conditions. Small, firm, non-tender nodules should raise suspicion and prompt further evaluation.
A: Asymmetry is normal in most males.
B: Marked tenderness could indicate inflammation or infection but is not necessarily abnormal.
C: Easy sliding of scrotal contents is a normal finding.
In summary, choice D is the correct answer due to the concerning nature of the nodules, while the other choices are either normal findings or not indicative of a serious issue.
Question 2 of 5
The nurse is assessing a client who reports cessation of menses. The nurse should document the cessation of menses in the client's record as:
Correct Answer: D
Rationale: The correct answer is D: menopause. Menopause is the natural process where a woman's menstrual periods stop permanently due to aging. Cessation of menses is a key characteristic of menopause. Salpingitis (
A) is inflammation of the fallopian tubes, adnexa (
B) refers to the accessory structures of the uterus, and menarche (
C) is the onset of menstruation in a young girl.
Therefore, these choices are incorrect as they do not relate to the cessation of menses.
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 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 5 of 5
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
Correct Answer: B
Rationale:
To assess cranial nerve III (oculomotor nerve), the nurse should check the pupillary response to light. This is because cranial nerve III controls the constriction of the pupil in response to light. By shining a light into the client's eyes, the nurse can observe the pupillary response, looking for equal and brisk constriction. This assessment helps to determine the integrity of cranial nerve III function. Observing for facial symmetry (choice
A) is related to cranial nerve VII (facial nerve). Testing visual acuity (choice
C) is related to cranial nerves II (optic nerve) and V (trigeminal nerve). Eliciting the gag reflex (choice
D) is related to cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve).