ATI RN
Multi Dimensional Care | Final Exam
1. What is the priority nursing diagnosis for a client with immobility?
- A. Constipation related to immobility
- B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
- D. Risk for disuse syndrome as evidenced by 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.
2. Which of the following is NOT a risk factor for osteoarthritis?
- A. Older age
- B. Sports injuries
- C. Obesity
- D. Vegan diet
Correct answer: D
Rationale:
3. What statement by the client indicates a correct understanding of the timing of progression of human immunodefiency virus (HIV) to acquired immunodeficiency syndrome?
- A. "Sexually transmitted infections will not make AIDS develop faster"?
- B. "My diet does not influence the progression of HIV to AIDS"?
- C. "If I practice medication, I may develop AIDS faster."?
- D. "IF I am re-exposed to HIV, the progression to AIDS may be faster,"?
Correct answer: D
Rationale:
4. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
- A. Client will increase mobility by the time of discharge from hospital
- B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
- C. Client will increase activity tolerance by discharge from the hospital
- D. Client will remain free from falls throughout their hospital stay
Correct answer: D
Rationale:
5. What is not a nursing intervention for a client with osteoporosis?
- A. Nurse will encourage the intake of adequate amounts of calcium and vitamin D
- B. Nurse will encourage the client to complete weight-bearing exercises
- C. Nurse will encourage the client to avoid muscle strengthening exercises
- D. Nurse will encourage the client to avoid repetitive movements
Correct answer: C
Rationale: The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.
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