ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
- A. “Ice packs can be used to reduce swelling but should be removed after 20 minutes.”
- B. “Heat always makes the swelling go down. You do not need any other interventions.”
- C. “Try high impact exercise exercise like running to loosen up your joints and reduce pain.”
- D. “Apply ice packs. It is generally okay to keep them on for up to one hour at a time.”
Correct answer: “Ice packs can be used to reduce swelling but should be removed after 20 minutes.”
Rationale:
2. What is not a nursing intervention for a client with osteoporosis?
- A. Nurse will encourage the intake of adequate amounts of calcium and vitamin D
- B. Nurse will encourage the client to complete weight-bearing exercises
- C. Nurse will encourage the client to avoid muscle strengthening exercises
- D. Nurse will encourage the client to avoid repetitive movements
Correct answer: C
Rationale: The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.
3. What is a symptom of the expected disease pattern of rheumatoid arthritis?
- A. Unilateral joint pain
- B. Bilateral joint pain
- C. Contralateral joint pain
- D. Obtuse variety joint pain
Correct answer: Bilateral joint pain
Rationale:
4. 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.
5. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?
- A. Applying moisturizer to dry areas of the skin
- B. Massaging the client’s reddened shoulders and heels
- C. Cleansing the skin routinely after soiling occurs
- D. Using a Hoyer lift for all transfers
Correct answer: Massaging the client’s reddened shoulders and heels
Rationale:
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