which of the following assessments is found in neurovascular compromise

ATI RN

Multi Dimensional Care | Final Exam

1. Which of the following assessments is found in neurovascular compromise?

A. Tingling
B. Strong pulses
C. Warm skin
D. Full range motion

Correct answer: A

Rationale: Tingling is a common sign of neurovascular compromise.

2. Which among the following is NOT the cause of pressure ulcers?

A. Immobility
B. Poor nutrition
C. Moisture
D. Adequate perfusion

Correct answer: D

Rationale:

3. A nurse is teaching a client who has a new prescription for ibuprofen to treat rheumatoid arthritis. The nurse should teach the client to monitor for what adverse effect of this medication?

A. Bleeding
B. Insomnia
C. Blurred vision
D. Constipation

Correct answer: C

Rationale:

4. 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.