ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
What is a classic symptom assessed in clients with lupus?
Correct Answer: A
Rationale: In clients with lupus, a classic symptom that is commonly assessed is the butterfly rash, which appears on the face resembling the shape of a butterfly across the cheeks and bridge of the nose. This rash is a hallmark sign of lupus and is often one of the first visible symptoms to appear. Option B, Chvostek's sign, is actually associated with hypocalcemia and is manifested as facial muscle spasms when the facial nerve is tapped. Option C, Ovid's sign, is a distractor as it is not a recognized medical sign or symptom in relation to lupus or any other condition. Option D, Heberden's nodes, are bony swellings that occur at the distal interphalangeal joints in osteoarthritis, which is not typically associated with lupus. Understanding these distinctions is crucial for healthcare providers to accurately assess and diagnose lupus in patients. Recognizing the key symptoms of lupus, such as the butterfly rash, aids in prompt intervention and management of the condition, ultimately improving patient outcomes.
Question 2 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 3 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 4 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.
Question 5 of 5
What statement by the client indicates a correct understanding of the timing of progression of human immunodefiency virus (HIV) to acquired immunodeficiency syndrome?
Correct Answer: D
Rationale: The correct answer is option D) "If I am re-exposed to HIV, the progression to AIDS may be faster." This statement reflects a correct understanding of the timing of progression from HIV to AIDS as it acknowledges that reinfection with HIV can accelerate the progression to AIDS. This is a crucial concept in HIV care as repeated exposure to the virus can lead to increased viral load and more rapid disease progression. Option A is incorrect because sexually transmitted infections can indeed impact the progression of HIV to AIDS through various means such as increasing inflammation and viral replication. Option B is also incorrect as diet can influence the immune system's ability to fight off infections, potentially affecting the progression of HIV to AIDS. Option C is incorrect because adherence to medication is essential in slowing down the progression of HIV to AIDS, not speeding it up. This highlights the importance of medication adherence in HIV management. Educationally, understanding the factors that can influence the progression of HIV to AIDS is crucial for individuals living with HIV and healthcare providers. Reinforcing the importance of safe sexual practices, medication adherence, and overall health maintenance can help individuals manage their condition effectively and improve their quality of life.