ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 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 2 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 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
During a community screening event for bone density an elderly client asked the nurse why she is an inch shorter in height. Which of the following responses by the nurse is correct?
Correct Answer: C
Rationale:
Correct Answer: C
Rationale: With aging, the cartilage between the bones in the spine gets worn down, leading to decreased height. This process is known as degenerative disc disease, where the intervertebral discs lose water content and become thinner, causing a reduction in height. As a result, the individual appears shorter. This explanation directly addresses the client's concern about the loss of height and the role of cartilage degeneration in this process.
Summary:
A: Subcutaneous fat loss does not directly contribute to decreased height.
B: Spinal flexibility may decrease with age but does not specifically account for reduced height.
D: Thickening of intervertebral discs and pressure breakdown do not lead to decreased height.
Therefore, option C is the most appropriate response as it accurately explains the mechanism behind the client's height loss.
Question 5 of 5
The nurse teaches a client that there are shock absorbers in the back to cushion the spine and to help it move. The client understands that which of the following is another name for shock absorbers:
Correct Answer: B
Rationale: The correct answer is B: Intervertebral disks. These disks act as shock absorbers between the vertebrae, cushioning the spine and helping it move. They are made of a tough outer layer called the annulus fibrosus and a gel-like inner core called the nucleus pulposus. The other choices are incorrect because: A. Vertebral column refers to the entire spine, not just the shock absorbers. C. Vertebral foramen is the opening through which the spinal cord passes, not related to shock absorption. D. Nucleus pulposus is part of the intervertebral disk, not another name for shock absorbers.