ATI RN
ATI Nursing 137 Exam 3 Fall 2023 Questions
Extract:
Question 1 of 5
The physician comments that the client has abdominal borborygmic. The nurse recognizes that which of the following is the best description of borborygmic?
Correct Answer: D
Rationale: The correct answer is D: Loud gurgling bowel sounds. Borborygmi are loud, prolonged, high-pitched gurgling bowel sounds caused by increased gastrointestinal motility. This indicates hyperactive bowel sounds.
A: A peritoneal friction rub is a sign of peritoneal inflammation, not related to bowel sounds.
B: Loud continual humming bowel sounds do not describe borborygmi, which are gurgling sounds.
C: Hypoactive bowel sounds are decreased or absent bowel sounds, opposite of borborygmi.
Question 2 of 5
A client states,I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness. Which of the following should the nurse expect as an assessment finding?
Correct Answer: B
Rationale: The correct answer is B: Crepitation. Crepitation refers to the crunching or grating sound heard when bones rub against each other due to cartilage wear. It is associated with osteoarthritis, which causes pain and stiffness, especially in the morning. Other choices are incorrect because:
A) Bone spur is a bony projection, not associated with sounds;
C) Tendonitis involves inflammation of tendons, not bones;
D) Fluid in the knee joint (effusion) can cause swelling but not the described symptoms.
Question 3 of 5
The nurse is educating a client on different areas of the brain. The nurse recognizes that which of the following statements concerning areas of the brain is correct?
Correct Answer: D
Rationale: The correct answer is D: The hypothalamus controls body temperature and regulates sleep. The hypothalamus plays a crucial role in maintaining homeostasis by regulating body temperature, hunger, thirst, and circadian rhythms, including sleep-wake cycles. It contains specialized nuclei that respond to internal and external stimuli to maintain a balanced internal environment. The other choices are incorrect because:
A) The basal ganglia are primarily involved in motor control and not voluntary movement.
B) Motor pathways synapse in the thalamus for sensory processing, not motor control.
C) The cerebellum is responsible for coordination, balance, and muscle tone, not speech and emotions.
Question 4 of 5
During an abdominal assessment,the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?
Correct Answer: C
Rationale: The correct answer is C: Appendix. Tenderness on light palpation in the right lower quadrant indicates possible inflammation of the appendix, which is a classic sign of appendicitis. The appendix is located in the right lower quadrant of the abdomen, making it the most likely organ causing the tenderness. Sigmoid (
A) is located in the left lower quadrant. Liver (
B) is located in the right upper quadrant. Gallbladder (
D) is located in the right upper quadrant.
Therefore, the appendix is the most likely organ causing the tenderness in the right lower quadrant.
Question 5 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.