ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client with systemic sclerosis (Scleroderma) is experiencing Raynaud's phenomenon. What assessment finding does the nurse anticipate?
- A. Excessive heartburn
- B. Cyanosis of the lips
- C. Excess wrinkled skin
- D. Cold and purple nailbeds
Correct answer: D
Rationale:
2. A nurse is teaching a client who has out about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?
- A. Fruit juice
- B. Alcohol
- C. Milk
- D. Coffee
Correct answer: B
Rationale:
3. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?
- A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
- B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
- C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
- D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'
Correct answer: A
Rationale:
4. By providing measures to reduce skin breakdown, how does the nurse break the chain of infection?
- A. Sterilizing the area to reduce the reservoir risk
- B. Maintaining the integrity of a portal of entry
- C. Creating a reservoir to decrease the risk of infection
- D. Creating a susceptible host
Correct answer: B
Rationale:
5. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer the client a bedpan for toileting
- C. Offer a protein-rich diet
- D. Turn the client every 2 hours
Correct answer: D
Rationale:
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