a nurse is caring for an immobile client what is the priority assessment of this client
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

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

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

2. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

Correct answer: A

Rationale:

3. What complication of fractures is caused by increased pressure which can result in decreased circulation to the area?

Correct answer: B

Rationale: Acute compartment syndrome is the correct answer. It involves increased pressure within muscles, leading to decreased blood flow and tissue damage. Venous thromboembolism (Choice A) is a condition where a blood clot forms in a vein, usually in the leg. Fat embolism syndrome (Choice C) occurs when fat globules enter the bloodstream and block blood vessels. Hemorrhage (Choice D) refers to bleeding, which can occur with fractures but does not specifically involve increased pressure leading to decreased circulation as in acute compartment syndrome.

4. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?

Correct answer: A

Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.

5. What is the term for a ringing in the ears reported by the client?

Correct answer: D

Rationale: Tinnitus is the correct answer. Tinnitus refers to the perception of noise or ringing in the ears. This condition can be constant or intermittent and may be caused by various factors such as exposure to loud noises, ear infections, or underlying health conditions. Choices A, B, and C are incorrect as Weber and Rinne tests are related to hearing assessment, while the pinna is the external part of the ear responsible for collecting sound waves.

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