ATI Geriatric 5 Cloned Assessment Detailed Answers Key 2023
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ATI Geriatric 5 Cloned Assessment 2023
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ATI Geriatric 5 Cloned Assessment 2023
ATI Geriatric 5 Cloned Assessment Detailed Answers Key 2023
During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect?
Detailed Answer Key Geriatric 5_Cloned_Assessment 1 Created on:08/05/2023 Page 1 1. During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect? A. Poor circulation Rationale: Poor circulation results in signs of neurovascular impairment, such as numbness and tingling or pain, rather than an area of warmth. B. Pressure from the cast Rationale: Pressure from the cast can occur over bony prominences or areas when the cast was handled while wet resulting in indentations in the cast. The client generally states having a burning discomfort, indicating neurovascular impairment. C. Uneven cast drying Rationale: Uneven cast drying results in a change in the cast appearance and may cause complications such as pressure areas to the skin. D. Infection Rationale: An area of warmth on a cast is an indication of an infection. The client may state feeling a painful area of heat at the site. The nurse should report this finding to the provider. 2. A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client to avoid movement of the affected leg. Rationale: The nurse should instruct the client on how to perform leg exercises to help prevent the development of venous thrombosis. B. Prevent hip flexion of the affected extremity Rationale: The nurse should implement measures to prevent hip flexion of the affected extremity beyond 90 degrees due to the risk of dislocation. Raised toilet seats and reclining chairs help prevent hyper -flexion. C. Position the lower extremities so that they are touching. Rationale: The nurse should use an abduction pillow or other positioning device to prevent hip adduction which can lead to dislocation. D. Ensure that the client’s heels are touching the bed. Rationale: The nurse should elevate the client’s heels off of the bed to help prevent skin breakdown. 3. A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the Detailed Answer Key Geriatric 5_Cloned_Assessment 1 Created on:08/05/2023 Page 2 following times? A. 0720 Rationale: Five to ten minutes is the lag time suggested for rapid acting insulin, but regular insulin is the short acting type with an onset of 30 minutes. B. 0730 Rationale: A fifteen minute interval between insulin administration and eating a meal is too short since the onset of regular insulin is 30 minutes. C. 0745 Rationale: Regular insulin should be given 20 to 30 minutes before eating because the onset of action is 30 minutes. There are circumstances when this lag time guide can be adjusted. D. 0815 Rationale: A one hour interval between insulin administration and eating a meal is too long since the onset of regular insulin is 30 minutes. 4. A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in which of the following positions? A. Adduction. Rationale: When carin g for a client following a total hip arthroplasty, the nurse should prevent adduction of the affected extremity due to the risk for dislocation. B. External rotation. Rationale: When caring for a client following a total hip arthroplasty, the nurse should prevent external rotation of the affected extremity due to the risk for dislocation. C. Internal rotation. Rationale: When caring for a client following a total hip arthroplasty, the nurse should prevent internal rotation of the affected extremity due to the risk for dislocation. D. Abduction. Rationale: When caring for a client following a total hip arthroplasty, the nurse should abduct the affected extremity to prevent dislocation, positioning the legs away from the midline. 5. A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome? A. Decreased radial pulse Rationale: Carpal tunnel syndrome does not affect radial pulsations, although it can cause numbness and Detailed Answer Key Geriatric 5_Cloned_Assessment 1 Created on:08/05/2023 Page 3 radiating pain. B. Positive Trousseau's sign Rationale: Positive Trousseau's sign is an indication of hypokalemia. The client's hand and fingers spasm in response to prolonged pressure from a blood pressure cuff applied to the upper arm. C. Cool extremities Rationale: Carpal tunnel syndrome does not affect the temperature of the hands, although it can cause swelling, discoloration, and brittle nails. D. Positive Phalen's sign Rationale: If a client who has carpal tunnel syndrome holds his wrist in flexion for 60 seconds, it will produce tingling and numbness over the median nerve, the palmar surface of the thumb, the index finger, the middle finger, and part of the ring finger. This is a positive Phalen's test. 6. A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take? A. Cover the wound with a sterile saline -soaked dressing. Rationale: The nurse should cover an eviscerated wound with sterile saline -soaked gauze to prevent damage and infection. B. Place the client in high -Fowler's position. Rationale: The nurse should place the client supine with the head of the bed elevated 15° to 20° with the hips and knees bent. C. Auscultate all quadrants of the abdomen for bowel sounds. Rationale: Using a stethoscope in the wound area can introduce bacteria and cause infection. D. Gently reinsert the protruding tissue. Rationale: The nurse should not attempt to reinsert the protruding organ or viscera into the abdominal cavity. By doing so, the nurse could cause further damage, such as perforation. 7. A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? A. Poor impulse control Rationale: A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment. B. Unable to discriminate words and letters Rationale: A client who had a stroke involving the left cerebral hemisphere is likely to have deficits that
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