ATI RN
Multi Dimensional Care | Rasmusson
1. What is the term for a ringing in the ears reported by the client?
- A. Weber
- B. Rinne
- C. Pinna
- D. Tinnitus
Correct answer: D
Rationale: Tinnitus is the correct answer. Tinnitus refers to the perception of noise or ringing in the ears. This condition can be constant or intermittent and may be caused by various factors such as exposure to loud noises, ear infections, or underlying health conditions. Choices A, B, and C are incorrect as Weber and Rinne tests are related to hearing assessment, while the pinna is the external part of the ear responsible for collecting sound waves.
2. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct answer: B
Rationale:
3. 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:
4. What complication of fractures is caused by increased pressure which can result in decreased circulation to the area?
- A. Venous thromboembolism
- B. Acute compartment syndrome
- C. Fat embolism syndrome
- D. Hemorrhage
Correct answer: B
Rationale: Acute compartment syndrome is the correct answer. It involves increased pressure within muscles, leading to decreased blood flow and tissue damage. Venous thromboembolism (Choice A) is a condition where a blood clot forms in a vein, usually in the leg. Fat embolism syndrome (Choice C) occurs when fat globules enter the bloodstream and block blood vessels. Hemorrhage (Choice D) refers to bleeding, which can occur with fractures but does not specifically involve increased pressure leading to decreased circulation as in acute compartment syndrome.
5. A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?
- A. Primary intention
- B. Binary intention
- C. Secondary intention
- D. None of the Above
Correct answer: A
Rationale:
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