ATI RN
ATI Nurse 142 Final Questions
Extract:
Question 1 of 5
Which of the following statements concerning breast examination is true?
Correct Answer: A
Rationale: Bimanual palpation is used to evaluate the tail of Spence, the breast tissue extending into the axilla. The axillae should always be palpated, nipple discharge is normal in pregnancy, and breasts are inspected in a consistent position to detect abnormalities.
Question 2 of 5
The nurse is performing a nutritional assessment. Which of the following would be considered objective data?
Correct Answer: C
Rationale: Objective data are measurable and observable findings that can be obtained through physical examination, laboratory tests, or other diagnostic procedures. Body Mass Index (BMI) is a calculated value based on height and weight, making it objective. Dietary history, patient complaints, and history of alcohol intake are subjective as they rely on the patient's self-report and may not be entirely accurate.
Question 3 of 5
When assessing a client for alcohol use, the nurse utilizes the CAGE acronym, what does E stand for?
Correct Answer: D
Rationale: In the CAGE screening tool for alcohol misuse, 'E' stands for 'Eye-opener,' referring to the need for a drink in the morning to function or relieve withdrawal symptoms. This indicates potential alcohol dependence.
Question 4 of 5
The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)
Correct Answer: A,B
Rationale: When checking for edema in congestive heart failure, the nurse grades the edema on a scale of +1 to +4 based on the depth of pitting and presses the skin over the tibia to assess for pitting edema. Plantar flexing the feet is unrelated to edema assessment, and checking only one limb is insufficient as edema may occur bilaterally.
Question 5 of 5
When assessing the breast, the nurse would teach the patient to palpate which of the following areas?
Correct Answer: A,B,C
Rationale: The nurse should teach the patient to palpate all four quadrants of the breast (upper outer, lower inner, upper inner) and the tail of Spence, the extension of breast tissue into the axilla. This ensures a comprehensive self-examination to detect any abnormalities.