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. On inspection, which client does the nurse suspect of having a visual impairment?
- A. The client whose sclera is white
- B. The client who has an intact blink reflex
- C. The client who is tilting their head
- D. The client with equal pupils
Correct answer: C
Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.
3. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?
- A. The pain will go away after the swelling decreases.
- B. That is phantom limb pain.
- C. Your foot has been amputated, so you are not having pain in that foot.
- D. On a scale of 0-10, how would you rate your pain?
Correct answer: D
Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.
4. What is not an inappropriate nursing intervention for psoriasis?
- A. Teach the client how to utilize UV radiation
- B. Apply rubbing alcohol to plaques
- C. Apply corticosteroids as ordered
- D. Urge the client to consider participating in support groups
Correct answer: B
Rationale:
5. What is the intended outcome for the treatment of glaucoma?
- A. Improve the vision of the eye
- B. Strengthen the muscles of the eye
- C. Lower the intraocular pressure
- D. Dry up excess secretions
Correct answer: C
Rationale: The correct answer is C: Lower the intraocular pressure. The primary objective of treating glaucoma is to reduce intraocular pressure to prevent further vision loss. Choice A, 'Improve the vision of the eye,' is incorrect because while treatment may prevent vision loss, it does not necessarily improve vision. Choice B, 'Strengthen the muscles of the eye,' is incorrect as glaucoma primarily involves the optic nerve and not muscle weakness. Choice D, 'Dry up excess secretions,' is not related to the treatment goal of glaucoma which is focused on managing intraocular pressure.
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