ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
Correct Answer: D
Rationale: In this scenario, the nurse's priority action should be to culture the wound (Option D). Culturing the wound is essential to identify the specific bacteria causing the infection, which will guide appropriate antibiotic therapy. By obtaining a wound culture, the nurse can ensure targeted treatment for the infection, leading to better outcomes for the client. Option A, inserting the wound and assessing the drainage, is not the priority action in this case. While wound assessment is important, obtaining a culture to identify the infectious organism takes precedence. Option B, applying topical ointment to the wound, may provide some symptomatic relief but does not address the underlying cause of the infection. Antibiotic therapy based on culture results is necessary for effective treatment. Option C, calling the provider to initiate antibiotics, is premature without knowing the specific bacteria causing the infection. Starting antibiotics without a culture may lead to inappropriate treatment and potential antibiotic resistance. In an educational context, understanding the rationale behind prioritizing actions in wound care is crucial for nursing practice. Emphasizing the importance of evidence-based interventions, such as wound cultures, reinforces the significance of thorough assessment and individualized treatment plans in providing quality patient care.
Question 2 of 5
The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Cataracts. Cataracts are characterized by a gradual clouding of the lens in the eye, leading to blurred vision. The client's complaint of constantly needing to clean his glasses and the absence of eye pain are indicative of cataracts. Option B) Diabetic retinopathy is unlikely in this case as there is no mention of the client having diabetes, which is a key risk factor for this condition. Option C) Corneal dystrophy affects the cornea, not the lens, and typically presents with symptoms different from those described by the client. Option D) Conjunctivitis is characterized by redness, itching, and discharge in the eye, none of which are mentioned by the client. In an educational context, this question helps reinforce the importance of recognizing common eye disorders based on specific symptoms and history provided by the client. Understanding these distinctions is crucial for effective nursing assessment and intervention in clinical practice.
Question 3 of 5
What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not?
Correct Answer: A
Rationale: The correct answer is A) The client with AIDS is a susceptible host. This is because individuals with AIDS have a compromised immune system due to the depletion of CD4 T cells, which are crucial in fighting infections. As a result, they are more susceptible to opportunistic infections like pneumonia, which can be caused by pathogens that a healthy person's immune system would normally combat effectively. Option B) The client with AIDS has greater immune defenses is incorrect because, in reality, individuals with AIDS have weakened immune defenses, not greater ones. This is a key characteristic of AIDS - the immune system is compromised, making the individual more vulnerable to infections. Option C) The client with AIDS was not as careful is incorrect and not relevant to the immune response and susceptibility to pneumonia. Carefulness or behavior is not a determining factor in the susceptibility of individuals with AIDS to infections like pneumonia. Option D) The client with AIDS has more portals of entry is incorrect because the number of portals of entry does not directly correlate with susceptibility to pneumonia. The primary factor at play in this scenario is the compromised immune system of the individual with AIDS. In an educational context, understanding why individuals with AIDS are more susceptible to certain infections is crucial in providing appropriate care and support for this population. It highlights the importance of infection control measures, vaccination, and early detection of infections in individuals with compromised immune systems. This knowledge is essential for healthcare professionals working with HIV/AIDS patients to ensure the best possible outcomes for their clients.
Question 4 of 5
A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?
Correct Answer: A
Rationale: In this scenario, the most concerning finding when assessing an area of skin over a bony prominence would be option A) Redness. Redness, also known as erythema, indicates localized inflammation and increased blood flow to the area, which can be a sign of early-stage pressure injury or skin breakdown. This finding is concerning because it suggests that tissue damage may be occurring due to prolonged pressure on the skin, leading to compromised blood flow and potential tissue necrosis. Option B) Non-blanching is incorrect because non-blanching erythema is a more severe sign of tissue damage that does not fade when pressure is applied. It indicates more advanced tissue injury compared to blanching erythema, where the redness fades when pressure is relieved. Option C) Blanching is incorrect because blanching erythema is a less concerning finding as the redness fades when pressure is applied, suggesting that the blood flow is still intact and the skin is not yet compromised. Option D) Warmth is incorrect because while warmth can be associated with inflammation, it is a less specific indicator of tissue damage compared to redness, which directly points towards localized inflammation and potential skin breakdown. Educationally, it is crucial for nurses to recognize the early signs of pressure injuries and skin breakdown to prevent complications in patients, especially those with limited mobility or sensory perception. Regular skin assessments, knowledge of risk factors, and prompt intervention are essential in providing quality care and preventing pressure ulcers. Recognizing the significance of skin findings like redness can help nurses take proactive measures to prevent further tissue damage and promote skin integrity.
Question 5 of 5
A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Shearing injury. When a client is positioned in High-Fowler's position, the skin layers may shift in opposite directions due to gravity and friction. This can lead to shearing forces, where the skin is pulled in different directions, causing damage to the underlying tissues. Shearing injuries are common in individuals who are immobile or have limited mobility, as their skin is more prone to damage from these forces. Option A, Traumatic injury, is incorrect as it does not specifically relate to the shifting of skin layers in opposite directions while in a seated position. Option B, Pressure injury, is also incorrect as it refers to damage caused by pressure on a specific area of the body, not the shearing forces experienced in High-Fowler's position. Option C, Friction injury, is not the most appropriate answer as it does not capture the unique mechanism of injury associated with shearing forces. In an educational context, understanding the risks associated with different positions and their impact on skin integrity is crucial for healthcare professionals, especially those working with immobile or bedridden patients. Proper positioning techniques and regular skin assessments can help prevent shearing injuries and other complications related to immobility.