a nurse working in an orthopedic unit is caring for 4 clients which of the following clients should the nurse identify as being at highest risk for sk
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

Correct answer: D

Rationale:

2. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?

Correct answer: B

Rationale:

3. What is correct about a nursing diagnosis?

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.

4. A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?

Correct answer: A

Rationale:

5. 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?

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.

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