ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?
- A. Once retinal detachment occurs, it does not return to its normal state
- B. Once the tissue has necrosed from high-pressure, it does not regenerate
- C. Glaucoma always leads to permanent blindness
- D. Once bacterial infection has caused damage, the tissue does not regenerate
Correct answer: B
Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
2. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?
- A. Encouraging bedrest
- B. Applying antiembolism stockings
- C. Tell the client to take anticoagulants
- D. Teaching about smoking cessation
Correct answer: B
Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.
3. A client recently had an above the knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing?
- A. Nociceptive
- B. Neuropathic
- C. Visceral
- D. Cutaneous
Correct answer: A
Rationale:
4. The client had surgery one day ago. What assessment is most likely related to pain?
- A. Blood pressure of 175/90 mm Hg
- B. Respirations of 10 breaths per minute
- C. Heart rate 60 beats/minute
- D. Oxygen saturation of 97%
Correct answer: A
Rationale:
5. During a skin inspection at the outpatient clinic, the nurse notices patches of thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect?
- A. Scabies
- B. Rosacea
- C. Psoriasis
- D. Statis dermatitis
Correct answer: C
Rationale:
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