ATI RN
Multi Dimensional Care | Final Exam
1. What is the priority nursing diagnosis for a client with metastatic bone disease?
- A. Chronic pain
- B. Impaired mobility
- C. Risk for falls
- D. Risk for infection
Correct answer: C
Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
2. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct answer: D
Rationale:
3. What evaluation indicates successful progress on the client goal of increasing daily physical activity?
- A. The client reports decreased social interaction
- B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
- C. The client reports a fall
- D. The client reports less fatigue walking up stairs
Correct answer: D
Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.
4. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?
- A. Because it is easy to digest.'
- B. Protein has amin acid that promotes wound healing.'
- C. If you do not like it, you do not have to take it.'
- D. These supplements have nothing to do with your wound,'
Correct answer: B
Rationale:
5. 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:
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