ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client has a new diagnosis of human immunodeficiency virus HIV. The client is distraught and does not know what to do. What intervention by the nurse is the best?
- A. Offer to tell the family for the client
- B. Call the hospital clergy to speak with the client
- C. Assess the client's support system
- D. Explain the legal requirements to tell sex partners
Correct answer: C
Rationale:
2. What is the priority nursing diagnosis for a client with immobility?
- A. Constipation related to immobility
- B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
- D. Risk for disuse syndrome as evidenced by immobility
Correct answer: C
Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.
3. What may be a cause of conductive hearing loss?
- A. Prolonged exposure to loud noises
- B. Medications
- C. Presbycusis
- D. Otitis media
Correct answer: D
Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.
4. What is the most common method of reducing and immobilizing a fracture?
- A. Open reduction with external fixation
- B. External reduction and internal fixation
- C. External fixation with closed reduction
- D. Open reduction with internal fixation
Correct answer: D
Rationale: Open reduction with internal fixation (ORIF) is the most common method for reducing and immobilizing fractures.
5. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?
- A. Observe client for changes in mental status
- B. Use aseptic technique for wound care and emptying of drains
- C. Keep the client's heels off the bed
- D. Perform neurovascular assessments per protocol
Correct answer: D
Rationale:
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