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. Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?
- A. I can spread this through contact with surfaces, so I need to wear gloves in public.'
- B. Because I have HIV, that means I'm an AIDS patient'
- C. I need to ensure that I place my needles in a proper needle disposal container.'
- D. I can still have unprotected intercourse with my partner since he does not have HIV.'
Correct answer: C
Rationale:
3. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?
- A. Creamy pus
- B. Serous
- C. Serosanguineous
- D. Purulent exudate
Correct answer: C
Rationale:
4. What nursing interventions increase the risk the pressure injuries?
- A. Padding hard surfaces
- B. Have client sit in wheelchair as much as possible
- C. Place pillows between bony surfaces
- D. Keep head of bed (HOB) at or less than 3
Correct answer: B
Rationale:
5. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
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