ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which assessment is NOT a nonverbal sing of pain?
- A. Decreased attention span
- B. Grimacing
- C. Increase in heart rate
- D. Reported pain of 5/10
Correct answer: D
Rationale:
2. 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.
3. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
- A. Position the client on one side with the head turned towards you
- B. Handle dentures with care
- C. Use gentle brushing and flossing techniques for clients with fragile mucosa
- D. Have a suction apparatus ready at the bedside
Correct answer: A
Rationale:
4. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?
- A. The UAP puts shoes on the client
- B. The UAP removes floor rugs and loose objects from the path
- C. The UAP walks to the side and slightly in front of the client
- D. The UAP uses a transfer (gait) belt
Correct answer: C
Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.
5. The client complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?
- A. "You just have arthritis and should take some ibuprofen."?
- B. "You should avoid walking. This might be osteoporosis."?
- C. "Please tell me more about when your pain started."?
- D. "You need to lose weight or the pain won't go away."?
Correct answer: C
Rationale:
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