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. Why do young infants usually cry?
- A. because they are bored
- B. in shrill, piercing tones
- C. because of physical needs
- D. all night long
Correct answer: C
Rationale: Young infants usually cry because of physical needs such as hunger, discomfort, or needing to be changed. It is their way of communicating these needs to their caregivers as they are unable to do so in any other way. Choice A is incorrect because infants cry primarily to communicate physical needs, not because they are bored. Choice B is incorrect because the tone of the cry is not the reason why infants cry. Choice D is incorrect because infants cry for various physical needs, not necessarily all night long.
3. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Apply a moisture-retentive dressing
- C. Apply a heating pad to the site
- D. Keep the client on bedrest
Correct answer: B
Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.
4. Paralysis of all or part of the trunk, legs, and pelvic organs is referred to as:
- A. Hemiplegia
- B. Tetraplegia
- C. Paraplegia
- D. Hemiparesis
Correct answer: C: Paraplegia
Rationale: Paraplegia is the paralysis of the lower half of the body, including both legs and often the trunk and pelvic organs. Hemiplegia refers to paralysis affecting one side of the body, while tetraplegia involves paralysis of all four limbs and the trunk. Hemiparesis is a partial weakness affecting one side of the body.
5. Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer’s type and confabulates. The nurse understands that this client:
- A. Denies confusion by being jovial.
- B. Pretends to be someone else.
- C. Rationalizes various behaviors.
- D. Fills in memory gaps with fantasy.
Correct answer: D
Rationale: Confabulation, a common symptom in dementia, involves filling in memory gaps with fabricated stories rather than intentionally pretending to be someone else (Choice B), denying confusion by being jovial (Choice A), or rationalizing various behaviors (Choice C). Confabulation is not a deliberate act but a memory error that results in the creation of false memories.
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