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. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?
- A. Hyperthermia
- B. A cold environment
- C. Normal
- D. Hypothermia
Correct answer: A
Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.
3. What are signs of hearing loss? (Select all that apply)
- A. Answering questions correctly
- B. Presence of cerumen
- C. Tinnitus
- D. Frequent asking of others to repeat statements
Correct answer: C
Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
4. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
- A. The client sets the cap down in a manner that does not contaminate it.
- B. The client drops the prescribed number of drops into the conjunctival sac
- C. The client washes their hands before instilling the drops
- D. The client ensures that they touch the administration dropper to the eye
Correct answer: D
Rationale: Touching the dropper to the eye contaminates it and can lead to infection.
5. What does CREST stand for?
- A. Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly and Telecines
- B. Calcinosis, Reverse isolation, Esophageal dysmotility, Sclerodactyly and Telangiectasia
- C. Calcinosis, Raynaud's, Everted colon, Sclerodactyly and Telangiectasia
- D. Calcinosis, Raynaud's Esophageal dysmotility, Sclerodactyly and telangiectasia
Correct answer: D
Rationale:
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