the nurse is planning care for a client with damage to the vestibular area of the vestibulocochlear nerve what should the nurse include in the plan of

ATI RN

ATI Pathophysiology Exam

1. The nurse is planning care for a client with damage to the vestibular area of the vestibulocochlear nerve. What should the nurse include in the plan of care? Select all that apply.

A. Assistance with ambulation
B. Regular hearing tests
C. Monitoring for nausea
D. Vision assessments

Correct answer: A

Rationale: Damage to the vestibular area affects balance and may cause nausea. Therefore, the nurse should include assistance with ambulation in the care plan to help the client maintain stability while walking. Regular hearing tests (choice B) are not directly related to damage in the vestibular area of the vestibulocochlear nerve. While nausea (choice C) may occur due to vestibular damage, monitoring for it alone is not as essential as providing assistance with ambulation. Vision assessments (choice D) are important for assessing visual function but are not the priority when dealing with vestibular issues.

2. In a 41-year-old male patient with a complex medical history diagnosed with secondary hypogonadism, which of the following health problems is the most likely etiology of his diagnosis?

A. Type 1 diabetes
B. Mumps
C. An inflammatory process in the testicles
D. Testicular trauma

Correct answer: C

Rationale: The correct answer is C: An inflammatory process in the testicles. Secondary hypogonadism in males can be caused by various factors, including an inflammatory process in the testicles. Mumps (choice B) can lead to orchitis but is less common in adults. Type 1 diabetes (choice A) is not a common cause of secondary hypogonadism. Testicular trauma (choice D) can cause primary hypogonadism but is less likely to cause secondary hypogonadism.

3. When does pain in the lower extremities due to peripheral artery disease usually worsen?

A. with rest because blood flow decreases.
B. with elevation of the extremity because blood is diverted away.
C. when the leg is in a dependent position because blood pools.
D. when the leg is touched or massaged because cytokines are released.

Correct answer: B

Rationale: Pain in the lower extremities due to peripheral artery disease usually worsens with elevation of the extremity because blood is diverted away from the affected area, leading to decreased perfusion and exacerbation of symptoms. Choices A, C, and D are incorrect because resting, dependent position, and touch/massage do not typically worsen the pain associated with peripheral artery disease.

4. A patient arrives at her follow-up appointment 1 month post-hysterectomy and complains to the nurse that her scars do not seem to be healing properly. Upon inspection, the nurse notices that the scars are raised but still within the boundaries of the original incisions. The nurse tells the patient this kind of dysfunctional wound healing is called:

A. Hypertrophic scarring
B. Dehiscence
C. Contracture
D. A keloid

Correct answer: A

Rationale: Hypertrophic scarring occurs when a scar is raised but remains within the boundaries of the original wound, unlike keloids, which extend beyond the wound edges. Dehiscence refers to the separation of wound edges, while contracture involves the tightening or constriction of a scar, leading to limited mobility.

5. What is a characteristic of coronary artery disease (CAD)?

A. The build-up of infectious by-products in the lymph nodes
B. Insufficient delivery of oxygenated blood to the myocardium
C. Insufficient delivery of carbon dioxide to the lungs
D. The build-up of bile in the stomach and gallbladder

Correct answer: B

Rationale: The correct characteristic of coronary artery disease (CAD) is the insufficient delivery of oxygenated blood to the myocardium. CAD is a condition where the coronary arteries become narrowed or blocked, leading to reduced blood flow to the heart muscle. This lack of oxygenated blood can result in chest pain, known as angina, and if a coronary artery becomes completely blocked, it can cause a heart attack. Choices A, C, and D are incorrect. Choice A refers to an issue related to the lymphatic system, choice C is about gas exchange in the lungs, and choice D describes a problem with bile accumulation in the digestive system, none of which are characteristics of CAD.