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 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: A
Rationale:
3. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer the client a bedpan for toileting
- C. Offer a protein-rich diet
- D. Turn the client every 2 hours
Correct answer: D
Rationale:
4. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
- A. Assess the right radial pulse
- B. Call the provider
- C. Administer pain medication
- D. Assess the right pedal pulse
Correct answer: A
Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.
5. 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:
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