where will the nurse collect the most reliable source of pain assessment

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. 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:

2. What is not a nursing intervention for a client with osteoporosis?

A. Nurse will encourage the intake of adequate amounts of calcium and vitamin D
B. Nurse will encourage the client to complete weight-bearing exercises
C. Nurse will encourage the client to avoid muscle strengthening exercises
D. Nurse will encourage the client to avoid repetitive movements

Correct answer: C

Rationale: The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.

3. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

A. Once bacterial infection has caused damage, the tissue does not regenerate.
B. Once retinal detachment occurs, it does not return to its normal state.
C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
D. Glaucoma always leads to permanent blindness.

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

4. Death of bone tissue can occur when the blood supply to the bone is disrupted. What is this complication called?

A. Reflex sympathetic dystrophy
B. Avascular necrosis
C. Delayed union
D. Complex regional pain syndrome

Correct answer: B

Rationale: The correct answer is B, avascular necrosis. Avascular necrosis is the condition where bone tissue dies due to the disruption of blood supply to the bone. Reflex sympathetic dystrophy (Choice A) is a chronic pain condition, delayed union (Choice C) refers to a delayed healing of a fracture, and complex regional pain syndrome (Choice D) is a chronic pain condition typically affecting an arm or leg.