an area of erythema on the childs skin is being assessed by the nurse the nurse presses down on the area and the area becomes white what time does the

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?

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

Correct answer: B

Rationale:

2. What is a negative effect of immobility on the cardiovascular system?

A. Increased high density lipoprotein
B. Increased circulation
C. Increased pumping action of the heart
D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

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 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.