the nurse is assessing a client who had a cast placed 4 hours ago what assessment finding is cause for concern
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

2. What are signs of hearing loss? (Select all that apply)

Correct answer: C

Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.

3. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

4. What is a negative effect of immobility on the musculoskeletal system?

Correct answer: B

Rationale: Contractures are a negative effect of immobility on the musculoskeletal system.

5. 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?

Correct answer: D

Rationale:

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