a client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain today the client came into the clinic complaining of he
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?

Correct answer: B

Rationale:

2. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

Correct answer: A

Rationale:

3. The nurse is performing a psychosocial assessment on a client with a severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?

Correct answer: C

Rationale:

4. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

5. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?

Correct answer: A

Rationale:

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