ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?
- A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
- B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
- C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
- D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?
Correct answer: B
Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.
2. What nursing interventions increase the risk the pressure injuries?
- A. Padding hard surfaces
- B. Have client sit in wheelchair as much as possible
- C. Place pillows between bony surfaces
- D. Keep head of bed (HOB) at or less than 3
Correct answer: B
Rationale:
3. What phase of wound healing occurs at the time of injury and lasts about 3-5 days?
- A. Maturation
- B. Intentional
- C. Inflammatory
- D. Proliferative
Correct answer: C
Rationale:
4. A client arrives speaking only Spanish. What is the priority nursing intervention?
- A. Give the client a tour of the unit
- B. Verify the reason for admission
- C. Request a medical interpreter
- D. Call the chaplain for support
Correct answer: C
Rationale:
5. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?
- A. Inquire about the frequency, quality and location of the pain
- B. Get the client pain medication
- C. Ensure the client knows he will have negative effects from immobility
- D. Review the client’s medication administration record
Correct answer: A
Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.
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