ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client recently had an above the knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing?
- A. Nociceptive
- B. Neuropathic
- C. Visceral
- D. Cutaneous
Correct answer: A
Rationale:
2. The client had surgery one day ago. What assessment is most likely related to pain?
- A. Blood pressure of 175/90 mm Hg
- B. Respirations of 10 breaths per minute
- C. Heart rate 60 beats/minute
- D. Oxygen saturation of 97%
Correct answer: A
Rationale:
3. The client with systemic sclerosis (Scleroderma) is experiencing Raynaud's phenomenon. What assessment finding does the nurse anticipate?
- A. Excessive heartburn
- B. Cyanosis of the lips
- C. Excess wrinkled skin
- D. Cold and purple nailbeds
Correct answer: D
Rationale:
4. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?
- A. The pain will go away after the swelling decreases.
- B. That is phantom limb pain.
- C. Your foot has been amputated, so you are not having pain in that foot.
- D. On a scale of 0-10, how would you rate your pain?
Correct answer: D
Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.
5. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?
- A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
- B. "An injured artery causes impaired arterial perfusion through the compartment."?
- C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
- D. . "A bone fragment has injured the nerve supply in the area."?
Correct answer: C
Rationale:
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