a nurse enters the hospital room of a client with reduced immunity what observation requires further action by the nurse
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

Correct answer: B

Rationale:

2. 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?

Correct answer: C

Rationale:

3. What should be done immediately after an ankle injury?

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.

4. What is correct health promotion education for vision? (Select all that apply)

Correct answer: D

Rationale: Wearing sunglasses, washing hands before touching eyelids, and wearing eye protection when working with fluids are important health promotion activities for vision.

5. The medical record for a client states that the client has hemiplegia. What does this mean?

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

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