a nurse is caring for an immobile client what is the priority assessment of this client

ATI RN

Multi Dimensional Care | Final Exam

1. A nurse is caring for an immobile client. What is the priority assessment of this client?

A. Palpate for edema
B. Auscultate for bowel sounds
C. Inspect the skin for injury
D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

2. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

A. Deeply palpate the area for rebound tenderness
B. Medicate the client for pain and reassess in 60 minutes
C. Percuss over the area for a change in tone
D. Compare the circumference to the left calf

Correct answer: D

Rationale:

3. What is the priority nursing diagnosis after surgery to repair a fracture?

A. Disturbed body image
B. Risk for infection
C. Risk for impaired skin integrity
D. Acute pain

Correct answer: B

Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.

4. What is the best goal for pain control in a client with RA?

A. The client will eat healthy meals today and stay hydrated
B. The client will have throughout the entire day
C. The client will have pain less than 3/10 for most of the day
D. The client will have pain less than 8/10 throughout the day

Correct answer: D

Rationale:

5. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

A. Two-point gait
B. Three-point gait
C. Four-point gait
D. Unaffected gait

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.