ATI RN
Multi Dimensional Care | Final Exam
1. 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.
2. A client with systemic lupus erythematous complains of flank pain. Which laboratory test does the nurse anticipate will be ordered?
- A. Platelets
- B. Skin biopsy
- C. Creatinine
- D. Hemoglobin
Correct answer: C
Rationale:
3. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?
- A. Administer antibiotics to the client
- B. Increase the client's protein intake
- C. Teach relaxation breathing to reduce the client's pain
- D. Provide the client with anti-pyretic therapy
Correct answer: A
Rationale:
4. The nurse is caring for 4 clients. What client should the nurse see first?
- A. A client with multiple children visiting
- B. A client with lupus asking for dinner
- C. A client on Methotrexate with a fever
- D. A client with chronic rheumatic pain
Correct answer: C
Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.
5. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?
- A. Tell the client’s family that they will be expected to stay overnight
- B. Apply restraints to the client
- C. Shout to the client
- D. Orient the client to the location of objects in the room
Correct answer: D
Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.
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