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 finding is often present in a client with osteoporosis?
- A. Chronic pain
- B. Dupuytren’s contracture
- C. Inflammation
- D. Kyphosis
Correct answer: D
Rationale: Kyphosis is a common finding in osteoporosis due to vertebral compression fractures. Chronic pain (Choice A) can occur in osteoporosis but is not a specific finding. Dupuytren’s contracture (Choice B) is a condition affecting hand fingers' connective tissue, not typically associated with osteoporosis. Inflammation (Choice C) is not a typical finding in osteoporosis but rather a characteristic of other conditions.
3. Which assessment is NOT a nonverbal sing of pain?
- A. Decreased attention span
- B. Grimacing
- C. Increase in heart rate
- D. Reported pain of 5/10
Correct answer: D
Rationale:
4. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?
- A. The client refused her pain medication this morning and is doing physical therapy.
- B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
- C. The client reports intermittent flatus and minor abdominal discomfort.
- D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.
Correct answer: D
Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.
5. A client just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy?
- A. "This must be hard news to hear. Tell me more about it."?
- B. "I believe you can overcome this because I have seen how strong you are."?
- C. "Tomorrow will be better."
- D. "What is your biggest fear about this diagnosis?"?
Correct answer: A
Rationale:
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