ATI RN
Client Comfort and End of Life Care ATI Quizlet Questions
Question 1 of 5
A client asks the nurse why pain seems worse when the client is tired. What would be the basis of the nurse's response?
Correct Answer: A
Rationale: The basis of the nurse's response is reduced pain tolerance, as fatigue lowers the brain's ability to modulate pain signals, heightening perceptionexhaustion depletes coping reserves, making pain feel worse without changing its source. This is a psychological-physiological link. Choice B, increased inflammation, isn't fatigue-driven; inflammation ties to disease, not tiredness alone. Choice C, poor circulation, may worsen some pain (e.g., ischemia), but fatigue's effect is broader, not vascular-specific. Choice D, muscle tension, could contribute, but fatigue typically relaxes muscles, not tenses themtolerance is key. Choice A is correct, guiding nurses to explain this perception shift, suggesting rest or timed analgesics to bolster tolerance, helping clients manage pain's amplified feel when tired.
Question 2 of 5
The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first?
Correct Answer: B
Rationale: When assessing a patient's abdomen, the nurse must follow a systematic approach to ensure accurate findings, starting with the least invasive technique. Inspection (Choice B) is the first step because it involves observing the abdomen for visible signs like distension, scars, or asymmetry without altering the body's natural state. Auscultation (Choice A) comes next, as it listens to bowel sounds, but performing percussion (Choice C) or palpation (Choice D) first could stimulate bowel motility or cause discomfort, potentially skewing the auscultation results. Inspection provides a baseline visual assessment, allowing the nurse to note abnormalities before proceeding to hands-on techniques. For instance, palpating or percussing too early might increase peristalsis, leading to misleading bowel sound interpretations. This sequenceinspection, auscultation, percussion, palpationis a standard protocol in nursing practice to maintain accuracy and patient comfort. Therefore, starting with inspection (Choice B) ensures the assessment is both logical and effective, making it the correct answer.
Question 3 of 5
A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, 'How long will it take for my scars to disappear?' Which statement would be the nurse's best response?
Correct Answer: C
Rationale: Diabetes mellitus delays wound healing due to impaired circulation, reduced immune response, and poor collagen formation, complicating predictions for a 65-year-old patient with a large wrist laceration. Choice C'With your history and the type of location of the injury, it's hard to say'is the best response because it acknowledges these variables without giving a definitive, potentially inaccurate timeline. Choice A (2 to 3 years') refers to the remodeling phase but overgeneralizes, as diabetes may prolong this. Choice B (within 4 months') is overly optimistic, as diabetic healing often exceeds this, especially for large wounds. Choice D (1 to 3 years') assumes no infection but still provides a broad, uncertain range. The nurse must avoid false reassurance; diabetes and age increase infection risk and slow tissue repair, while the wrist's mobility may further delay healing. Choice C's ambiguity reflects clinical reality, encouraging follow-up discussion, making it the most appropriate and correct response.
Question 4 of 5
A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
Correct Answer: B
Rationale: Pressure ulcers require optimal nutrition for healing, and inadequate protein intake (Choice B) is the most likely reason for non-healing despite repositioning and skin care. Protein is essential for collagen synthesis, tissue repair, and immune function; deficiency causes negative nitrogen balance, stalling granulation and epithelialization. Prolonged bed rest already reduces muscle mass, exacerbating protein needs. Vitamin D (Choice A) aids calcium absorption for bone health, not directly wound healing, though it supports overall recovery. Massaging the affected area (Choice C) is contraindicated, as it damages fragile tissue, and isn't part of standard care here. Low calcium (Choice D) affects bones more than soft tissue repair. For example, a client needing 1.5-2 g/kg protein daily but receiving less won't heal, even with turning, as protein fuels fibroblast activity and angiogenesis. Thus, Choice B is the correct and primary factor.
Question 5 of 5
A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
Correct Answer: B
Rationale: A WBC count of 100/µL (normal: 4,500-11,000) indicates severe leukopenia, likely neutropenia, making infection prevention (Choice B) the most important goal. With Hb (14 g/dL, normal: 13.5-17.5) and HCT (40%, normal: 38-50%) within range, anemia or fluid imbalance isn't a concern, ruling out fluid balance (Choice A) and rest (Choice C). Injury prevention (Choice D) is less urgent, as bleeding risk requires low platelets, not specified here. A WBC this lowe.g., post-chemotherapyleaves the client defenseless against pathogens; even minor infections can become septic. Interventions like isolation, hand hygiene, or antibiotics prioritize this risk. For example, a fever in neutropenia is a medical emergency, unlike fatigue or bruising. Survival hinges on infection control, making Choice B the correct and critical goal.