a client with lupus experience raynauds phenomenon what should the nurse include when providing client education about this
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?

Correct answer: A

Rationale:

2. What is correct about a nursing diagnosis?

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

3. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?

Correct answer: B

Rationale:

4. What occurs during stage three of bone healing?

Correct answer: B

Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.

5. What is a priority intervention when caring for a client in Buck’s traction?

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.

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