ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What should the nurse do first if they are stuck by a needle?
- A. Seek medical attention
- B. Flush the exposed skin with water
- C. Complete an incident report
- D. Report the exposure
Correct answer: B
Rationale:
2. Which assessment is NOT a nonverbal sing of pain?
- A. Decreased attention span
- B. Grimacing
- C. Increase in heart rate
- D. Reported pain of 5/10
Correct answer: D
Rationale:
3. What is the priority nursing diagnosis for a client with immobility?
- A. Constipation related to immobility
- B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
- D. Risk for disuse syndrome as evidenced by 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.
4. Which of the following is NOT a risk factor for osteoarthritis?
- A. Older age
- B. Sports injuries
- C. Obesity
- D. Vegan diet
Correct answer: D
Rationale:
5. What is the best nursing intervention for a client with limited mobility who cannot move independently?
- A. Passive range of motion
- B. Pillows for positioning
- C. Active range of motion
- D. Continuous passive motion
Correct answer: A
Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.
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