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 fin

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. 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:

2. Which client is at highest risk of compromised immunity?

A. A client who just had surgery
B. A client who just delivered a baby
C. A client with extreme anxiety
D. A client who is awaiting surgery

Correct answer: A

Rationale:

3. Which finding is not typically associated with inflammation in a client?

A. Pain
B. Heat
C. Polyuria
D. Erythema

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.