a client who is sitting in high fowlers position is at risk for what type of injury as the skin layers shift in opposite directions

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: D

Rationale:

2. What does CREST stand for?

A. Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly and Telecines
B. Calcinosis, Reverse isolation, Esophageal dysmotility, Sclerodactyly and Telangiectasia
C. Calcinosis, Raynaud's, Everted colon, Sclerodactyly and Telangiectasia
D. Calcinosis, Raynaud's Esophageal dysmotility, Sclerodactyly and telangiectasia

Correct answer: D

Rationale:

3. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

A. The client's incision site has eviscerated
B. The client's incision site has lacerated
C. The client's incisional site is approximated
D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

4. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.