ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur?
- A. Tachycardia
- B. Raynaud's phenomenon
- C. Intense wrinkle
- D. Joint pain
Correct answer: B
Rationale:
2. What is a priority intervention when caring for a client in Buck’s traction?
- A. Adjust the size of the traction weights PRN as needed
- B. Discontinue the traction once the client has pain relief
- C. Ensure the traction weights rest on the floor
- D. Assess skin integrity
Correct answer: D
Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.
3. 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.
4. The nurse is caring for 4 clients. Which of these clients will the nurse see first?
- A. A client with sudden and increasing pain in his fractured arm
- B. A client being discharged in 2 hours and needs to be taught how to use his crutches
- C. A client with RA and a scheduled pain medication
- D. A client with a fractured ankle who would like a glass of water
Correct answer: A
Rationale:
5. What is not an inappropriate nursing intervention for psoriasis?
- A. Teach the client how to utilize UV radiation
- B. Apply rubbing alcohol to plaques
- C. Apply corticosteroids as ordered
- D. Urge the client to consider participating in support groups
Correct answer: B
Rationale:
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