ATI RN
Multi Dimensional Care | Rasmusson
1. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?
- A. Tell the client’s family that they will be expected to stay overnight
- B. Apply restraints to the client
- C. Shout to the client
- D. Orient the client to the location of objects in the room
Correct answer: D
Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.
2. Death of bone tissue can occur when the blood supply to the bone is disrupted. What is this complication called?
- A. Reflex sympathetic dystrophy
- B. Avascular necrosis
- C. Delayed union
- D. Complex regional pain syndrome
Correct answer: B
Rationale: The correct answer is B, avascular necrosis. Avascular necrosis is the condition where bone tissue dies due to the disruption of blood supply to the bone. Reflex sympathetic dystrophy (Choice A) is a chronic pain condition, delayed union (Choice C) refers to a delayed healing of a fracture, and complex regional pain syndrome (Choice D) is a chronic pain condition typically affecting an arm or leg.
3. During a skin inspection at the outpatient clinic, the nurse notices patches of thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect?
- A. Scabies
- B. Rosacea
- C. Psoriasis
- D. Statis dermatitis
Correct answer: C
Rationale:
4. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?
- A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
- B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
- C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
- D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'
Correct answer: A
Rationale:
5. A client has AIDS. Which of these findings indicate possible infection?
- A. Respirations; 22 breaths per minute
- B. Client ambulates 20 feet
- C. Purulent drainage
- D. Oxygen saturation; 97% on room air
Correct answer: C
Rationale:
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