ATI RN
Multi Dimensional Care | Final Exam
1. 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.
2. The understanding of genetic influences on behavior may never be fully achieved due to ________.
- A. the ease of researching to differentiate between the effects of the environment and genes.
- B. the likelihood that most behaviors are determined by the interaction of many genes and the environment.
- C. the reliance on twin studies in genetic research.
- D. our significant understanding of how genes impact brain chemistry.
Correct answer: B
Rationale: The correct answer is B because most behaviors are influenced by the interaction of multiple genes and the environment. Choice A is incorrect because it suggests that researching the effects of the environment and genes is easy, which is not the case. Choice C is incorrect as it focuses on a specific method (twin studies) rather than the broader concept of gene-environment interaction. Choice D is incorrect as the statement implies a high level of understanding that contradicts the idea that genetic influences on behavior may never be fully understood.
3. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has?
- A. Cataracts
- B. Diabetic retinopathy
- C. Corneal dystrophy
- D. Conjunctivitis
Correct answer: Cataracts
Rationale:
4. The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What information should the nurse include?
- A. Advise bed rest until 1 week after the icteric phase.
- B. Teach infection control measures to family members.
- C. Inform the mother that the child cannot return to school until 3 weeks after onset of jaundice.
- D. Reassure the mother that hepatitis A cannot be transmitted to other family members.
Correct answer: B
Rationale: Teaching infection control measures is crucial as Hepatitis A is highly contagious, especially in household settings. Proper hand hygiene and avoiding sharing personal items can prevent the spread of the virus within the family. Option A is incorrect because bed rest is not typically required for hepatitis A. Option C is incorrect as the child can return to school once feeling well and no longer contagious, not necessarily after a specific duration. Option D is incorrect because hepatitis A can be transmitted through contaminated food, water, or close personal contact.
5. A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select ONE that does not apply)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Pain at insertion site
- D. Sudden onset of shortness of breath
Correct answer: A
Rationale: In a client with a mediastinal chest tube, the presence of pink sputum does not necessarily require immediate intervention. However, tracheal deviation could indicate a tension pneumothorax, sudden shortness of breath could signal tube issues or pneumothorax, and drainage exceeding 70 mL/hr might suggest hemorrhage. Disconnection at the Y site could lead to air entering the tubing, necessitating prompt attention.
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