ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
- A. Intense cold therapy to the extremities
- B. Encourage ultraviolet (UV) light exposure
- C. Administer topical hydrocortisone
- D. Administer antibiotics
Correct answer: C
Rationale:
2. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?
- A. The client refused her pain medication this morning and is doing physical therapy.
- B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
- C. The client reports intermittent flatus and minor abdominal discomfort.
- D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.
Correct answer: D
Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.
3. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?
- A. I will drink at least 3000 mL of water daily."?
- B. . 'I will shower every day in hot water."?
- C. I will avoid tights belts."?
- D. I will use a humidifier during the winter months."?
Correct answer: B
Rationale:
4. Where will the nurse collect the most reliable source of pain assessment?
- A. From the nurse-to-nurse bedside report
- B. From a medical surgical book
- C. From the client
- D. From the client's chart
Correct answer: C
Rationale:
5. 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.
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