a nurse assesses an area of skin over a bony prominence what finding would be most concerning

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?

A. Redness
B. Non-blanching
C. Blanching
D. Warmth

Correct answer: A

Rationale:

2. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?

A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?

Correct answer: B

Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.

3. What should be done immediately after an ankle injury?

A. Immobilize, heat, compress, and elevate the ankle
B. Rest, ice, compress, and lower the ankle
C. Rest, ice, compress, and elevate the ankle
D. Rest, incubate, confine, and lower the ankle

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.

4. What occurs during stage three of bone healing?

A. Consolidation
B. Callus formation
C. Granulation formation
D. Hematoma formation

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.