the medical record for a client states that the client has hemiplegia what does this mean
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. 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.

2. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

3. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

Correct answer: D

Rationale:

4. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

Correct answer: D

Rationale:

5. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?

Correct answer: B

Rationale:

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