ATI RN
Multi Dimensional Care | Final Exam
1. 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.
2. Which of the following clients should be placed in isolation for airborne precautions?
- A. A high school wrestling championship with a rash
- B. A client that recently travelled and developed a fever with cough
- C. A client with an unknown skin infection
- D. A client with heart palpitations
Correct answer: B
Rationale:
3. 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.
4. What is the priority nursing diagnosis after surgery to repair a fracture?
- A. Disturbed body image
- B. Risk for infection
- C. Risk for impaired skin integrity
- D. Acute pain
Correct answer: B
Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.
5. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?
- A. Once bacterial infection has caused damage, the tissue does not regenerate.
- B. Once retinal detachment occurs, it does not return to its normal state.
- C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
- D. Glaucoma always leads to permanent blindness.
Correct answer: C
Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.
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