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. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?
- A. The client refused her pain medication this morning and is doing physical therapy.
- B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
- C. The client reports intermittent flatus and minor abdominal discomfort.
- D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.
Correct answer: D
Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.
3. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?
- A. Avoid contact sports until the infection has cleared
- B. Use a bath sponge to cleanse the skin
- C. Wash hands with soap and water before and after touching the infected area
- D. Use an antibacterial soap when showering
Correct answer: B
Rationale:
4. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present
Correct answer: D
Rationale:
5. 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.
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