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. Where will the nurse collect the most reliable source of pain assessment?
- A. From the nurse-to-nurse bedside report
- B. From a medical surgical book
- C. From the client
- D. From the client's chart
Correct answer: C
Rationale:
3. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present
Correct answer: D
Rationale:
4. The client with RA complains of intensely dry eyes. What does the nurse suspect?
- A. Systemic sclerosis
- B. Sjogren's syndrome
- C. Chron's disease
- D. Discoid lupus
Correct answer: B
Rationale:
5. What is correct health promotion education for vision? (Select all that apply)
- A. Wear sunglasses to filter ultraviolet (UV) light
- B. Avoid nonsteroidal anti-inflammatory drug (NSAID) use
- C. Wash your hands before touching your eyelids
- D. All of The Above
Correct answer: D
Rationale: Wearing sunglasses, washing hands before touching eyelids, and wearing eye protection when working with fluids are important health promotion activities for vision.
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