ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client who is sitting in High-Fowler’s position is at risk for what type of injury as the skin layers shift in opposite directions?
- A. Traumatic injury
- B. Pressure injury
- C. Friction injury
- D. Shearing injury
Correct answer: Shearing injury
Rationale:
2. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?
- A. Offer fluids every 2 hours.
- B. Document the client's behavior prior to being placed in seclusion.
- C. Discuss with the client their inappropriate behavior prior to seclusion.
- D. Assess the client's behavior every hour.
Correct answer: B
Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.
3. Which nursing diagnosis has nutritional implications?
- A. impaired dentition
- B. disruption of gas exchange
- C. self-esteem disturbance
- D. sleep pattern disturbance
Correct answer: A
Rationale: Impaired dentition affects a patient's ability to chew and consume a variety of foods, leading to potential nutritional deficiencies and malnutrition.
4. Which of the following terms refers to weakness of both legs and the lower part of the trunk?
- A. Paraparesis
- B. Hemiplegia
- C. Quadriparesis
- D. Paraplegia
Correct answer: B
Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.
5. A 54-year-old man presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after spending an afternoon building a deck on a very hot, humid day. The physician assessing the man is performing a differential diagnosis as part of her assessment. Which finding would suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature?
- A. Absence of sweating
- B. Shivering
- C. Lack of thirst
- D. Increased heart rate
Correct answer: B
Rationale: Shivering is a physiological response to fever, as the body attempts to generate heat to increase the internal temperature. Hyperthermia, on the other hand, does not involve shivering. Absence of sweating (choice A) is more indicative of hyperthermia, as the body struggles to cool down without sweating. Lack of thirst (choice C) can be seen in both fever and hyperthermia. Increased heart rate (choice D) can occur in both fever and hyperthermia due to the body's attempt to regulate temperature.
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