NUR 207: ATI Medical |! |! |! |!
Terminology Exam with accurate |! |! |!
answers & rationales
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A nurse is completing a client assessment for admission to the medical unit.
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Which of the following abdominal assessment findings require further
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investigation by the nurse? |! |! |!
A. Symmetrical Convex shape sphere
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B.Concave umbilicus |!
C.Bilateral bowel sounds in lower quadrants
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D.Ecchymosis - Correct answer ✔D. Ecchymosis |! |! |! |! |!
Rationale: Ecchymosis is a finding outside of the expected reference range for
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an abdominal assessment and would require the nurse to further investigate
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for potential injury, bleeding disorder, or physical abuse.
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A nurse is admitting an older client who has a suspected cognitive disorder.
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Which of the following inventories should be included as part of the
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admission assessment? |! |!
,A.Mental Status Examination (MSE)
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B.Brief Patient Health Questionnaire (Brief PHQ)
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C.Abnormal Involuntary Movements Scale (AIMS) |! |! |! |!
D.Scale for Assessment of Negative Symptoms (SANS) - Correct answer ✔A.
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Mental Status Examination (MSE)
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Rationale: The use of an MSE assists in identifying deterioration in mental
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status and brain damage, which are findings associated with cognitive
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disorders
A nurse is assessing a client who has ataxia. Which of the following actions
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should the nurse take to evaluate the client's ability to safely ambulate?
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A.Observe for the presence of Kernig's sign
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B.Perform a Romberg's test |! |! |!
C.Check the function of cranial nerve V
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, D.Inspect for the presence of clubbing - Correct answer ✔B.Perform a
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Romberg's test |!
Rationale: The nurse should perform a Romberg's test to check the client's
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ability to maintain an upright position without swaying when standing with
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feet close together, with eyes open and with eyes closed. The nurse must
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stand close enough to prevent the client from falling.
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A nurse in an emergency department is caring for a client who had a seizure
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and became unresponsive after stating she had a sudden, severe headache
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and vomiting. The client's vital signs are as follows: blood pressure 198/110
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mmH, pulse 82/min, respirations of 24/min, and a temperature of 38.2C
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(100.8F). Which of the following neurologic disorders should the nurse
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suspect?
A.Transient ischemic attack (TIA) |! |! |!
B.Hemorrhagic stroke |! |!
C.Thrombotic stroke |!
D.Embolic stroke - Correct answer ✔B.Hemorrhagic stroke
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Rationale: A client who has a hemorrhagic stroke often experience a sudden
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onset of symptoms including sudden onset of a severe headache, a decrease
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in the level of consciousness, and seizures. Hemorrhagic strokes occur when
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Terminology Exam with accurate |! |! |!
answers & rationales
|! |! |!
A nurse is completing a client assessment for admission to the medical unit.
|! |! |! |! |! |! |! |! |! |! |! |! |!
Which of the following abdominal assessment findings require further
|! |! |! |! |! |! |! |! |!
investigation by the nurse? |! |! |!
A. Symmetrical Convex shape sphere
|! |! |! |!
B.Concave umbilicus |!
C.Bilateral bowel sounds in lower quadrants
|! |! |! |! |!
D.Ecchymosis - Correct answer ✔D. Ecchymosis |! |! |! |! |!
Rationale: Ecchymosis is a finding outside of the expected reference range for
|! |! |! |! |! |! |! |! |! |! |! |!
an abdominal assessment and would require the nurse to further investigate
|! |! |! |! |! |! |! |! |! |! |!
for potential injury, bleeding disorder, or physical abuse.
|! |! |! |! |! |! |!
A nurse is admitting an older client who has a suspected cognitive disorder.
|! |! |! |! |! |! |! |! |! |! |! |! |!
Which of the following inventories should be included as part of the
|! |! |! |! |! |! |! |! |! |! |! |!
admission assessment? |! |!
,A.Mental Status Examination (MSE)
|! |! |!
B.Brief Patient Health Questionnaire (Brief PHQ)
|! |! |! |! |!
C.Abnormal Involuntary Movements Scale (AIMS) |! |! |! |!
D.Scale for Assessment of Negative Symptoms (SANS) - Correct answer ✔A.
|! |! |! |! |! |! |! |! |! |! |!
Mental Status Examination (MSE)
|! |! |!
Rationale: The use of an MSE assists in identifying deterioration in mental
|! |! |! |! |! |! |! |! |! |! |! |!
status and brain damage, which are findings associated with cognitive
|! |! |! |! |! |! |! |! |! |!
disorders
A nurse is assessing a client who has ataxia. Which of the following actions
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
should the nurse take to evaluate the client's ability to safely ambulate?
|! |! |! |! |! |! |! |! |! |! |!
A.Observe for the presence of Kernig's sign
|! |! |! |! |! |!
B.Perform a Romberg's test |! |! |!
C.Check the function of cranial nerve V
|! |! |! |! |! |!
, D.Inspect for the presence of clubbing - Correct answer ✔B.Perform a
|! |! |! |! |! |! |! |! |! |! |!
Romberg's test |!
Rationale: The nurse should perform a Romberg's test to check the client's
|! |! |! |! |! |! |! |! |! |! |! |!
ability to maintain an upright position without swaying when standing with
|! |! |! |! |! |! |! |! |! |! |!
feet close together, with eyes open and with eyes closed. The nurse must
|! |! |! |! |! |! |! |! |! |! |! |! |!
stand close enough to prevent the client from falling.
|! |! |! |! |! |! |! |!
A nurse in an emergency department is caring for a client who had a seizure
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
and became unresponsive after stating she had a sudden, severe headache
|! |! |! |! |! |! |! |! |! |! |!
and vomiting. The client's vital signs are as follows: blood pressure 198/110
|! |! |! |! |! |! |! |! |! |! |! |!
mmH, pulse 82/min, respirations of 24/min, and a temperature of 38.2C
|! |! |! |! |! |! |! |! |! |! |!
(100.8F). Which of the following neurologic disorders should the nurse
|! |! |! |! |! |! |! |! |! |!
suspect?
A.Transient ischemic attack (TIA) |! |! |!
B.Hemorrhagic stroke |! |!
C.Thrombotic stroke |!
D.Embolic stroke - Correct answer ✔B.Hemorrhagic stroke
|! |! |! |! |! |!
Rationale: A client who has a hemorrhagic stroke often experience a sudden
|! |! |! |! |! |! |! |! |! |! |! |!
onset of symptoms including sudden onset of a severe headache, a decrease
|! |! |! |! |! |! |! |! |! |! |! |!
in the level of consciousness, and seizures. Hemorrhagic strokes occur when
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