ATI RN
Multi Dimensional Care | Final Exam Questions
Question 1 of 5
The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
Correct Answer: A
Rationale: Atelectasis refers to the partial or complete collapse of lung tissue, often caused by inadequate lung expansion due to immobility, shallow breathing, or obstruction. Preventing atelectasis in clients with impaired mobility requires interventions that promote lung expansion and ventilation. **Option A (Assist the client to orthopneic position)** is correct because the orthopneic position—sitting upright and leaning slightly forward with arms supported on a table or overbed tray—maximizes lung expansion by reducing pressure on the diaphragm and allowing for deeper breaths. This position is especially beneficial for clients with respiratory compromise, as it improves alveolar ventilation and prevents the pooling of secretions that could lead to atelectasis. By facilitating deeper inhalation, it counteracts the shallow breathing patterns common in immobile clients. **Option B (Offer a protein-rich diet)** is incorrect because while nutrition is important for overall health and tissue repair, a protein-rich diet does not directly address the mechanical issue of lung collapse. Atelectasis is primarily a respiratory complication, not a nutritional one. Although proper nutrition supports immune function and healing, it does not improve lung expansion or secretion clearance, which are the primary mechanisms for preventing atelectasis. **Option C (Offer the client a bedpan for toileting)** is incorrect because using a bedpan does not promote lung expansion. In fact, prolonged bedpan use may contribute to immobility and discomfort, which can exacerbate shallow breathing. Encouraging mobility (e.g., assisting the client to a chair or commode) would be more beneficial for respiratory function, as movement helps stimulate deeper breathing and circulation. **Option D (Turn the client every 4 hours)** is incorrect because turning every 4 hours is insufficient to prevent atelectasis in most cases. While repositioning is important for preventing pressure injuries and improving circulation, it does not guarantee adequate lung expansion. More frequent turning (e.g., every 2 hours) combined with deep breathing exercises or incentive spirometry would be more effective. The orthopneic position is a more targeted intervention for directly addressing lung ventilation. The key to preventing atelectasis lies in interventions that actively promote lung expansion and secretion mobilization. The orthopneic position achieves this by optimizing the mechanics of breathing, whereas the other options either address unrelated needs or are insufficiently targeted to respiratory function.
Question 2 of 5
A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
Correct Answer: A
Rationale: The rationale for the correct answer and incorrect choices in this scenario is as follows: **Assess the right radial pulse (Correct Answer):** A crushing injury to the arm can lead to **compartment syndrome**, vascular damage, or nerve compression, all of which can compromise circulation and sensation. Numbness in the hand suggests possible **neurovascular impairment**, making immediate assessment of the radial pulse critical. The radial pulse is the most direct way to evaluate blood flow to the affected limb. If the pulse is weak, absent, or asymmetrical compared to the other arm, it indicates **ischemia** or **vascular injury**, requiring urgent intervention (e.g., surgical evaluation or compartment pressure measurement). Additionally, a diminished pulse alongside numbness supports the possibility of **nerve compression secondary to swelling or hematoma**. Thus, assessing circulation first ensures timely detection of life- or limb-threatening complications before proceeding with other interventions. **Call the provider (Incorrect Choice):** While notifying the provider is necessary, it should not be the *first* action without initial assessment data. The nurse must first **gather objective findings** (e.g., pulse strength, capillary refill, motor function) to provide the provider with a complete clinical picture. Calling without assessment risks delays in critical information, potentially leading to miscommunication or inadequate urgency in the provider’s response. For example, if the radial pulse is absent, the nurse can immediately escalate the situation as an emergency; if present, they may instead report stable findings with ongoing monitoring. **Administer pain medication (Incorrect Choice):** Pain management is important but **not the priority** in this case. Numbness, rather than pain, is the primary symptom, signaling potential **neurovascular compromise** rather than just tissue damage. Administering analgesics (especially opioids) could mask worsening symptoms (e.g., increasing pain unrelieved by medication, a red flag for compartment syndrome). Additionally, analgesics do not address the underlying cause of numbness, which could escalate to permanent damage if circulation is not restored promptly. Pain relief should follow *after* ensuring perfusion and nerve function are intact. **Assess the right pedal pulse (Incorrect Choice):** The pedal pulse is irrelevant in this context because the injury is localized to the **arm**. Assessing a lower extremity pulse would not provide information about vascular integrity in the affected limb. While systemic circulation checks (e.g., blood pressure) are part of trauma assessments, the focus here must be on the **right arm’s neurovascular status**. A pedal pulse assessment delays critical evaluation of the injury site and could result in missing signs of **compartment syndrome or arterial occlusion** specific to the arm. In summary, the correct sequence is to **first assess the radial pulse** to determine circulatory integrity, then proceed with provider notification or interventions based on findings. The incorrect choices either delay essential assessment, address non-urgent needs, or focus on unrelated systems, potentially compromising patient outcomes.
Question 3 of 5
What may be a cause of conductive hearing loss?
Correct Answer: D
Rationale: Conductive hearing loss occurs when sound waves cannot efficiently travel through the outer or middle ear to reach the inner ear. This can be due to physical blockages, structural abnormalities, or conditions affecting the ear's conductive pathway. **Otitis media (D)**, an infection or inflammation of the middle ear, is a classic cause of conductive hearing loss. Fluid buildup or pus in the middle ear space impedes the movement of the ossicles (tiny bones) and eardrum, disrupting sound conduction. This is particularly common in children due to their shorter, more horizontal Eustachian tubes, which are prone to blockages. The fluid's presence dampens vibrations, leading to temporary hearing impairment until the infection resolves or is treated. **Prolonged exposure to loud noises (A)** typically causes sensorineural hearing loss, not conductive. This type of damage affects the hair cells in the cochlea or the auditory nerve, impairing the conversion of sound vibrations into neural signals. While noise-induced hearing loss is a leading cause of auditory deficits, it doesn’t involve the mechanical obstruction characteristic of conductive loss. **Medications (B)**, particularly ototoxic drugs like certain antibiotics (e.g., gentamicin) or chemotherapy agents, also cause sensorineural hearing loss. These substances damage the inner ear’s delicate structures or the auditory nerve, disrupting neural signal transmission. Unlike conductive loss, this damage is often irreversible and doesn’t involve physical barriers in the outer or middle ear. **Presbycusis (C)** is age-related hearing loss and is exclusively sensorineural. It results from degenerative changes in the cochlea, auditory nerve, or brain’s auditory processing centers over time. While it shares symptoms like difficulty hearing high frequencies with some conductive losses, the underlying mechanism is entirely different—no physical blockage or middle ear dysfunction is involved. The key distinction lies in the affected anatomical region: conductive loss involves the outer/middle ear’s mechanical pathway, while sensorineural loss stems from inner ear or neural damage. Otitis media directly interferes with conduction, making it the only correct choice here. The other options, while significant causes of hearing impairment, belong to a separate category of auditory dysfunction. Understanding these differences is critical for accurate diagnosis and treatment, as conductive losses (e.g., from infections or earwax) are often treatable, whereas sensorineural losses may require hearing aids or cochlear implants.
Question 4 of 5
What are signs of hearing loss? (Select all that apply)
Correct Answer: C
Rationale: **Rationale:** **Choice C (Tinnitus) is correct** because tinnitus—a ringing, buzzing, or hissing sound in the ears—is a common symptom of hearing loss. It often results from damage to the hair cells in the cochlea or other auditory pathways, which can occur due to noise exposure, aging (presbycusis), or medical conditions. Tinnitus is frequently associated with sensorineural hearing loss, as the brain may compensate for reduced auditory input by generating phantom sounds. While tinnitus can occur independently, its presence alongside other symptoms strongly suggests hearing impairment. **Choice A (Presence of cerumen) is incorrect** because earwax (cerumen) is a normal bodily secretion that protects the ear canal. While excessive cerumen can cause temporary conductive hearing loss by blocking sound waves, its mere presence is not a definitive sign of hearing loss. Many individuals have cerumen without any auditory issues, and the problem is easily resolved with proper ear hygiene or medical removal. **Choice B (Presence of cerumen) is repeated and thus redundant**. It is the same as Choice A, and the rationale for its incorrectness remains identical. Redundant options in a question are typically errors and should not be considered valid distinct choices. **Choice D (Frequent asking of others to repeat statements) is incorrect** in this context because while it is a behavioral sign of hearing difficulty, the question specifies "signs of hearing loss," which typically refer to physiological or sensory indicators (e.g., tinnitus). Behavioral cues like asking for repetitions are secondary manifestations rather than direct signs. However, in clinical practice, this would still be relevant for diagnosing hearing impairment—just not the best fit for this question’s phrasing. The focus on **tinnitus (C)** as the correct answer highlights a primary sensory symptom directly linked to hearing loss mechanisms, whereas the other options either describe normal physiology (cerumen) or indirect behavioral effects (asking for repetitions). The repetition of Choice B further invalidates it as a distinct option. Understanding the distinction between direct symptoms and secondary effects is critical for accurately identifying hearing loss.
Question 5 of 5
A nurse is caring for an immobile client. What is the priority assessment of this client?
Correct Answer: C
Rationale: Immobility significantly increases the risk of pressure injuries (pressure ulcers) due to prolonged pressure on bony prominences, reduced blood flow, and potential shear forces from sliding or improper repositioning. The skin integrity of an immobile client must be inspected frequently—ideally every 2 hours—because early signs of injury (e.g., erythema, blisters, or tissue breakdown) require immediate intervention to prevent progression to severe wounds. Pressure injuries can develop rapidly (within hours) and lead to infections, prolonged hospitalization, or systemic complications. This makes skin inspection the **priority** assessment, as it addresses the most immediate and preventable threat to the client’s well-being. **Why other options are incorrect:** - **A: Palpate for edema** While edema assessment is important (e.g., for detecting DVT or fluid retention), it is not the **priority** for an immobile client. Edema may develop over time and is less immediately life-threatening than skin breakdown. Additionally, edema alone does not guide urgent interventions unless paired with other symptoms (e.g., pain or asymmetry suggesting thrombosis). - **B: Auscultate for bowel sounds** Immobility can slow gastrointestinal motility (leading to constipation or ileus), but bowel sounds are not the **first** priority. Bowel dysfunction typically develops over days and is not as immediately harmful as skin compromise. Monitoring bowel function is important but secondary to preventing pressure injuries. - **D: Auscultation of lung sounds** While immobility increases the risk of atelectasis or pneumonia due to shallow breathing, lung sounds are not the **priority** in the initial assessment. Respiratory complications usually manifest later (e.g., after 48–72 hours of immobility). Skin inspection takes precedence because it can prevent irreversible damage with early detection. In summary, **C** is correct because skin inspection directly addresses the most urgent and preventable complication of immobility (pressure injuries), while the other assessments are important but secondary in the immediate context. The rationale aligns with nursing priorities: preventing harm that is both rapid in onset and high in severity.