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. What is an example of proper body mechanics when lifting?

A. Lifting the object with your back
B. Standing with a narrow stance
C. Lifting excessive weight to strengthen the muscles
D. Holding the object close to the body

Correct answer: D

Rationale: Proper body mechanics include holding objects close to the body to prevent injury.

3. What may be a cause of conductive hearing loss?

A. Prolonged exposure to loud noises
B. Medications
C. Presbycusis
D. Otitis media

Correct answer: D

Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.

4. What can the nurse NOT teach a client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection?

A. Share toothpaste with family members
B. Avoid raw fruits and vegetables
C. Avoid cleaning your toothbrush with bleach
D. Wash your hands thoroughly

Correct answer: A

Rationale:

5. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?

A. Hyperthermia
B. A cold environment
C. Normal
D. Hypothermia

Correct answer: A

Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.