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 post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?
- A. The client's incision site has eviscerated
- B. The client's incision site has lacerated
- C. The client's incisional site is approximated
- D. The client's incisional site has dehisced after.
Correct answer: A
Rationale:
3. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?
- A. Maintain the client's blood pressure
- B. Call a chaplain
- C. Provide the spouse a chair
- D. Ask the client's spouse to explain what happened
Correct answer: A
Rationale:
4. What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
- A. Intense cold therapy to the extremities
- B. Encourage ultraviolet (UV) light exposure
- C. Administer topical hydrocortisone
- D. Administer antibiotics
Correct answer: C
Rationale:
5. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
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