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. What is the best nursing intervention for a client with limited mobility who cannot move independently?
- A. Passive range of motion
- B. Pillows for positioning
- C. Active range of motion
- D. Continuous passive motion
Correct answer: A
Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.
3. A client is diagnosed with glaucoma. The provider needs to determine if it is open-angle glaucoma or closed-angle glaucoma. What test does the nurse anticipate?
- A. Ultrasonic imaging
- B. Gonioscopy
- C. Corneal staining
- D. Electroretinography
Correct answer: B
Rationale: Gonioscopy is the appropriate test to anticipate in this scenario. It is used to distinguish between open-angle and closed-angle glaucoma by examining the angle where the iris meets the cornea. Choice A, ultrasonic imaging, is not typically used to differentiate between these types of glaucoma. Choice C, corneal staining, is used to detect corneal abrasions and defects, not to differentiate between types of glaucoma. Choice D, electroretinography, is a test that measures the electrical responses of various cell types in the retina and is not specific to differentiating between open-angle and closed-angle glaucoma.
4. Which test is used in the diagnosis of osteoporosis?
- A. Phalen's maneuver
- B. Dual-energy X-ray absorptiometry (DXA) scan
- C. Proprioception
- D. Blood culture
Correct answer: B
Rationale: The correct answer is B, Dual-energy X-ray absorptiometry (DXA) scan, which is commonly used to diagnose osteoporosis by measuring bone mineral density. Phalen's maneuver (choice A) is a test used to assess for carpal tunnel syndrome and is not related to osteoporosis. Proprioception (choice C) refers to the sense of body position and is not a diagnostic test for osteoporosis. Blood culture (choice D) is used to detect infections caused by bacteria in the bloodstream and is not relevant to the diagnosis of osteoporosis.
5. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?
- A. Administer pain medication
- B. Use proper hand hygiene and strict infection control
- C. Delegate all client personal care to specific unlicensed assistive personnel
- D. Plate the client in contact precautions
Correct answer: B
Rationale:
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