what is the priority nursing diagnosis for a client with immobility
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

2. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

Correct answer: A

Rationale:

3. On inspection, which client does the nurse suspect of having a visual impairment?

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

4. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

Correct answer: D

Rationale:

5. When providing a routine bed bath, what action does the nurse complete first?

Correct answer: D

Rationale:

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