ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 of 5
The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?
Correct Answer: C
Rationale: The correct answer is C because eating red meat can cause the stool to appear non-tarry and black due to the breakdown of the heme in the meat during digestion. This is known as pseudomelena.
Choice A, taking an iron supplement, typically results in tarry stools.
Choice B, dry heaves, is not directly related to stool color.
Choice D, loss of appetite, is also unrelated to stool color changes. It is essential for the nurse to document this finding as normal to prevent unnecessary concern or interventions.
Question 2 of 5
The nurse is preparing to screen a client for deep vein thrombosis (DVT). Which of the following techniques should the nurse recognize as the appropriate technique to screen for DVT?
Correct Answer: B
Rationale: The correct answer is B: measure the calf at the widest point with a tape measure. This technique is appropriate for screening DVT because measuring the calf at the widest point helps assess for swelling, a common sign of DVT. This method provides a baseline measurement that can help monitor changes in calf size, indicating potential clot formation. Measuring the circumference of the ankle (choice
A) is not as effective as the calf measurement in detecting DVT. Checking the dorsalis pedis pulse (choice
C) or compressing it (choice
D) are not relevant for screening DVT, as DVT is primarily diagnosed through imaging studies like ultrasound rather than pulse assessment.
Question 3 of 5
A 60-year-old man has been told that he has benign prostatic hypertrophy (BPH). He expresses that his friend just died from prostate cancer and that he is concerned about dying from cancer. Which of the following is an appropriate response by the nurse?
Correct Answer: D
Rationale:
Correct Answer: D. The enlargement of your prostate is caused by hormonal changes, and not cancer.
Rationale: Benign prostatic hypertrophy (BPH) is a non-cancerous condition commonly seen in older men due to hormonal changes. Prostate cancer is a separate condition. By reassuring the patient that BPH is not cancer-related and is due to hormonal changes, the nurse addresses the patient's fear and provides accurate information. This response helps alleviate the patient's concerns about dying from cancer, promoting understanding and reducing anxiety.
Summary:
A: Incorrect. Dismissing the patient's concerns without providing factual information can increase anxiety.
B: Incorrect. Chemotherapy is not a standard treatment for BPH and may confuse the patient.
C: Incorrect. Claiming that the swelling is temporary and will go away is inaccurate and may lead to false hopes.
D: Correct. Explains the cause of BPH, differentiating it from cancer, and provides reassurance.
E, F, G:
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 V?
Correct Answer: D
Rationale: The correct answer is D: Ask them to clench their teeth. This assesses cranial nerve V, the trigeminal nerve, which controls the muscles involved in chewing. By asking the client to clench their teeth, the nurse can observe the strength and symmetry of the jaw muscles, which are innervated by this nerve. This test helps to assess the motor function of the trigeminal nerve.
Choice A, listening to the client's speech, is not related to cranial nerve V.
Choice B, asking them to read a Snellen chart, assesses cranial nerve II, the optic nerve.
Choice C, asking them to identify scented aromas, assesses cranial nerve I, the olfactory nerve.
Question 5 of 5
The nurse is teaching a male client about the reproductive system. The nurse recognizes that which structure secretes a thin milky alkaline fluid to enhance the viability of sperm?
Correct Answer: A
Rationale: The correct answer is A: Cowper gland. The Cowper gland, also known as the bulbourethral gland, secretes a thin milky alkaline fluid that helps to neutralize the acidity of the urethra and enhance the viability of sperm. This fluid also lubricates the urethra, aiding in the passage of sperm during ejaculation. The other choices are incorrect because the prostate gland mainly produces a milky alkaline fluid to nourish and protect sperm, while the median sulcus is a groove on the surface of the prostate. The Cowper gland is the specific structure responsible for secreting the described fluid, making it the correct choice in this scenario.