ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client with systemic sclerosis (Scleroderma) is experiencing Raynaud's phenomenon. What assessment finding does the nurse anticipate?
- A. Excessive heartburn
- B. Cyanosis of the lips
- C. Excess wrinkled skin
- D. Cold and purple nailbeds
Correct answer: D
Rationale:
2. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?
- A. Inquire about the frequency, quality and location of the pain
- B. Get the client pain medication
- C. Ensure the client knows he will have negative effects from immobility
- D. Review the client’s medication administration record
Correct answer: A
Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.
3. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
- A. Use a mechanical lift to reposition the client every 2 hours
- B. Elevate the client's head of the bed to 45 degrees
- C. Postpone daily bed bath
- D. Caregiver independently slides the client up in the bed
Correct answer: A
Rationale:
4. The nurse is caring for 4 clients. Which of these clients will the nurse see first?
- A. A client with rheumatoid arthritis and a scheduled pain medication
- B. A client being discharged in 2 hours and needs to be taught how to use crutches
- C. A client with sudden and increasing pain in a fractured arm
- D. A client with a fractured ankle who would like a glass of water
Correct answer: C
Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.
5. 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?
- A. Scabies
- B. Rosacea
- C. Psoriasis
- D. Statis dermatitis
Correct answer: C
Rationale:
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