the provider orders the client to be placed in a high fowlers position at what angle will the nurse position the client

ATI RN

Multi Dimensional Care | Final Exam

1. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?

A. 15 degrees
B. 0 degrees
C. 90 degrees
D. 30 degrees

Correct answer: C

Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.

2. A nurse is caring for an immobile client. What is the priority assessment of this client?

A. Palpate for edema
B. Auscultate for bowel sounds
C. Inspect the skin for injury
D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

3. What is correct about a nursing diagnosis?

A. It is a human response to disease, injury, or other stressors.
B. It remains constant as long as the disease is present.
C. It is a way to identify pathology.
D. It is a disease, illness, or injury.

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

4. The medical record for a client states that the client has hemiplegia. What does this mean?

A. The client can use his right arm, left leg, and left arm.
B. The client has paralysis of all four extremities.
C. The client has decreased vision in one eye.
D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.