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 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 3 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).
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 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.