ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has?
- A. Cataracts
- B. Diabetic retinopathy
- C. Corneal dystrophy
- D. Conjunctivitis
Correct answer: A
Rationale:
2. What is the priority nursing diagnosis for a client with immobility?
- A. Constipation related to immobility
- B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
- D. Risk for disuse syndrome as evidenced by immobility
Correct answer: C
Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.
3. Which of the following statements made by a client diagnosed with human immunodefiency virus (HIV) would require further teaching?
- A. "I will have to be careful and avoid crowds."?
- B. "I will take prescribed medications."?
- C. "I will have to take medications for the rest of my life."?
- D. "I will only need to take HIV medications for 6 months, and I will be cured
Correct answer: D
Rationale:
4. 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.
5. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?
- A. Maintain the client's blood pressure
- B. Call a chaplain
- C. Provide the spouse a chair
- D. Ask the client's spouse to explain what happened
Correct answer: A
Rationale:
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