ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. 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:
2. A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?
- A. Redness
- B. Non-blanching
- C. Blanching
- D. Warmth
Correct answer: A
Rationale:
3. A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur?
- A. Tachycardia
- B. Raynaud's phenomenon
- C. Intense wrinkle
- D. Joint pain
Correct answer: B
Rationale:
4. 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.
5. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?
- A. Avoid exercise during flare-ups
- B. Do high impact exercises like running
- C. Establish a regular sleep pattern
- D. Increase calcium and caffeine intake
Correct answer: C
Rationale:
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