ATI RN
Multi Dimensional Care | Rasmusson
1. Which test is used in the diagnosis of osteoporosis?
- A. Phalen's maneuver
- B. Dual-energy X-ray absorptiometry (DXA) scan
- C. Proprioception
- D. Blood culture
Correct answer: B
Rationale: The correct answer is B, Dual-energy X-ray absorptiometry (DXA) scan, which is commonly used to diagnose osteoporosis by measuring bone mineral density. Phalen's maneuver (choice A) is a test used to assess for carpal tunnel syndrome and is not related to osteoporosis. Proprioception (choice C) refers to the sense of body position and is not a diagnostic test for osteoporosis. Blood culture (choice D) is used to detect infections caused by bacteria in the bloodstream and is not relevant to the diagnosis of osteoporosis.
2. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present
Correct answer: D
Rationale:
3. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
- A. Client will increase mobility by the time of discharge from hospital
- B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
- C. Client will increase activity tolerance by discharge from the hospital
- D. Client will remain free from falls throughout their hospital stay
Correct answer: D
Rationale:
4. What is a negative effect of immobility on the cardiovascular system?
- A. Increased high density lipoprotein
- B. Increased circulation
- C. Increased pumping action of the heart
- D. Venous stasis
Correct answer: D
Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.
5. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct answer: A
Rationale: The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.
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