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 client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
- A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
- B. "Heat always makes the swelling go down. You do not need any other interventions."?
- C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
- D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?
Correct answer: A
Rationale:
3. A client has a new arm cast. What is incorrect teaching by the nurse?
- A. Use a sling to alleviate fatigue
- B. Elevate the arm above the heart to reduce swelling
- C. Report ‘hot spots’ felt under the cast
- D. Sudden increase in drainage is expected
Correct answer: D
Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
4. What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not?
- A. The client with AIDS is a susceptible host
- B. The client with AIDS has greater immune defenses
- C. The client with AIDS was not as careful
- D. The client with AIDS has more portals of entry
Correct answer: A
Rationale:
5. 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.
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