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. Death of bone tissue can occur when the blood supply to the bone is disrupted. What is this complication called?
- A. Reflex sympathetic dystrophy
- B. Avascular necrosis
- C. Delayed union
- D. Complex regional pain syndrome
Correct answer: B
Rationale: The correct answer is B, avascular necrosis. Avascular necrosis is the condition where bone tissue dies due to the disruption of blood supply to the bone. Reflex sympathetic dystrophy (Choice A) is a chronic pain condition, delayed union (Choice C) refers to a delayed healing of a fracture, and complex regional pain syndrome (Choice D) is a chronic pain condition typically affecting an arm or leg.
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. A client has a new diagnosis of human immunodeficiency virus HIV. The client is distraught and does not know what to do. What intervention by the nurse is the best?
- A. Offer to tell the family for the client
- B. Call the hospital clergy to speak with the client
- C. Assess the client's support system
- D. Explain the legal requirements to tell sex partners
Correct answer: C
Rationale:
5. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct answer: B
Rationale:
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