a nurse is caring for an immobile client what is the priority assessment in this client

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse is caring for an immobile client. What is the priority assessment in this client?

A. Auscultation of lung sounds
B. Assessment of skin turgor
C. Auscultation of bowel sounds
D. Assessment for the presence of peripheral edema

Correct answer: A

Rationale:

2. The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?

A. I walk 3 miles every day. Would you like to join me?
B. Tell me more about your experience with these exercises.
C. My dad never exercised. He fell and broke his hip. Is that your goal?
D. You should be doing these exercises.

Correct answer: B

Rationale: The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.

3. What is correct about a nursing diagnosis?

A. It is a human response to disease, injury, or other stressors.
B. It remains constant as long as the disease is present.
C. It is a way to identify pathology.
D. It is a disease, illness, or injury.

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.