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. A client has a new arm cast. What is incorrect teaching by the nurse?
- A. Use a sling to alleviate fatigue
- B. Elevate the arm above the heart to reduce swelling
- C. Report ‘hot spots’ felt under the cast
- D. Sudden increase in drainage is expected
Correct answer: D
Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
3. What may be a cause of conductive hearing loss?
- A. Prolonged exposure to loud noises
- B. Medications
- C. Presbycusis
- D. Otitis media
Correct answer: D
Rationale: Otitis media can cause conductive hearing loss by affecting the middle ear.
4. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?
- A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
- B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
- C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
- D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?
Correct answer: B
Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.
5. What is correct about a nursing diagnosis?
- A. It is a human response to disease, injury, or other stressors.
- B. It remains constant as long as the disease is present.
- C. It is a way to identify pathology.
- D. It is a disease, illness, or injury.
Correct answer: A
Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.
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