the nurse has documented the following wound assessment shallow open reddened ulcer with no slough on the anterior region of the right heel what stage

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?

A. Stage 3
B. Stage 4
C. Stage 1
D. Stage 2

Correct answer: D

Rationale:

2. What occurs during stage three of bone healing?

A. Consolidation
B. Callus formation
C. Granulation formation
D. Hematoma formation

Correct answer: B

Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.

3. Which of the following nonpharmacological methods cannot be used to manage the chronic pain of a client with rheumatoid arthritis?

A. Adequate rest
B. Heat for 20-30 minutes
C. Hot showers
D. Ice for 2 hours at a time

Correct answer: D

Rationale:

4. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

A. Two-point gait
B. Three-point gait
C. Four-point gait
D. Unaffected gait

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

5. What is the intended outcome for the treatment of glaucoma?

A. Improve the vision of the eye
B. Strengthen the muscles of the eye
C. Lower the intraocular pressure
D. Dry up excess secretions

Correct answer: C

Rationale: The correct answer is C: Lower the intraocular pressure. The primary objective of treating glaucoma is to reduce intraocular pressure to prevent further vision loss. Choice A, 'Improve the vision of the eye,' is incorrect because while treatment may prevent vision loss, it does not necessarily improve vision. Choice B, 'Strengthen the muscles of the eye,' is incorrect as glaucoma primarily involves the optic nerve and not muscle weakness. Choice D, 'Dry up excess secretions,' is not related to the treatment goal of glaucoma which is focused on managing intraocular pressure.