ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?
- A. Once retinal detachment occurs, it does not return to its normal state
- B. Once the tissue has necrosed from high-pressure, it does not regenerate
- C. Glaucoma always leads to permanent blindness
- D. Once bacterial infection has caused damage, the tissue does not regenerate
Correct answer: B
Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
2. What soft tissue musculoskeletal injury is excessive stretching of a ligament?
- A. Sprain
- B. Ligament tear
- C. Strain
- D. Tendon rupture
Correct answer: A
Rationale: A sprain is an injury involving excessive stretching of a ligament.
3. What is the condition called when the client's pupils are different sizes and have been this way since childhood?
- A. Exophthalmos
- B. Anisocoria
- C. Strabismus
- D. Scleral edema
Correct answer: B
Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.
4. The nurse is performing a psychosocial assessment on a client with a severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?
- A. "Tell me about what medication you are taking"?
- B. "What physical limitations are you experiencing?"?
- C. "How does this impact your role in your family?"?
- D. "What therapies are you using to reduce swelling?"?
Correct answer: C
Rationale:
5. Which of the following assessments is found in neurovascular compromise?
- A. Tingling
- B. Strong pulses
- C. Warm skin
- D. Full range motion
Correct answer: A
Rationale: Tingling is a common sign of neurovascular compromise.
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