ATI RN
Multi Dimensional Care | Final Exam
1. A nurse is assessing a client with hallux valgus. What is another term for this assessment finding?
- A. Thoracic deformity
- B. A bunion
- C. A corn
- D. Metacarpal involvement
Correct answer: B
Rationale: Hallux valgus is commonly known as a bunion, which is a bony bump that forms on the joint at the base of the big toe. A) Thoracic deformity is unrelated to hallux valgus. C) A corn is a thickened area of skin on the foot, not synonymous with hallux valgus. D) Metacarpal involvement refers to the hand, not the foot where hallux valgus occurs.
2. What is the nurse's priority action for a client with compromised immunity?
- A. Wash hands before entering the client's room
- B. Take the client's vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct answer: A
Rationale:
3. What is the condition called when the client's pupils are different sizes and have been this way since childhood?
- A. Exophthalmos
- B. Anisocoria
- C. Strabismus
- D. Scleral edema
Correct answer: B
Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.
4. Which nonpharmacological intervention does not help reduce edema?
- A. Heat therapy
- B. Passive range of motion (PROM)
- C. Elevation of the extremity
- D. Cold therapy
Correct answer: A
Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.
5. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?
- A. Shearing or friction
- B. Twisting and bending
- C. Pressure or gravity
- D. Chemical or pressure
Correct answer: A
Rationale:
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