ATI RN
Client Comfort and End of Care Questions
Question 1 of 5
A client with hypoparathyroidism is suspected of having hypocalcemia. Upon assessment, the nurse notes which clinical symptom would indicate hypocalcemia.
Correct Answer: D
Rationale: Twitching indicates hypocalcemia in hypoparathyroidism, due to neuromuscular irritability from low calcium. Diminished reflexes and hypoactive bowels suggest hypercalcemia. Negative Trousseau's contradicts hypocalcemia's positive sign. Nurses, per NCLEX, recognize twitching as a key sign, making D correct.
Question 2 of 5
Which of the following findings must be immediately reported to the primary healthcare provider?
Correct Answer: D
Rationale: A purple stoma suggests ischemia or necrosis, requiring immediate reporting. Red stoma , excoriation , and stool are manageable. Nurses, per NCLEX, prioritize critical changes, making D correct.
Question 3 of 5
In giving information about a resident, it is often helpful to use the SBAR. In SBAR, there are four parts of the message you want to give; each one goes with one of the letters in SBAR. SBAR stands for:
Correct Answer: A
Rationale: SBAR Situation, Background, Assessment, Recommendationstructures resident info effectively, per the answer key. It outlines the issue, context, evaluation, and action needed. Choices B, C, and D are nonsensical or irrelevant. Nurses, per AHRQ and nursing practice, use SBAR for concise, standardized communication, especially in long-term care where clarity prevents errors and enhances team response.
Question 4 of 5
What is a primary nursing intervention for sleep-rest disorders?
Correct Answer: B
Rationale: A primary nursing intervention for sleep-rest disorders is promoting a consistent sleep routine, which helps regulate the body's circadian rhythm and improve sleep quality. This includes maintaining regular bedtimes, creating a calming pre-sleep environment, and minimizing disruptions. Choice A, encouraging late-night activities, would worsen sleep difficulties by stimulating the patient when they should be winding down. Choice C, increasing caffeine intake, is counterproductive as caffeine is a stimulant that interferes with sleep onset and quality. Choice D, limiting fluid intake all day, is impractical and unrelated to sleep improvementwhile reducing fluids before bed might prevent nighttime awakenings, all-day restriction risks dehydration. Choice B is the best approach, as it addresses the root of many sleep-rest issues by fostering habits that support restorative sleep, a critical aspect of patient recovery and well-being.
Question 5 of 5
What is the best way to assess comfort in a nonverbal patient?
Correct Answer: B
Rationale: Assessing comfort in a nonverbal patient relies heavily on observing body language, such as facial expressions, posture, or movements, since they can't verbally express pain or distress. Grimacing, restlessness, or guarding an area signal discomfort, while relaxed features or calm breathing suggest ease. Choice A, asking direct questions, is ineffective for nonverbal patients who can't respond, like those with dementia or intubation. Choice C, relying on family reports only, is limitingwhile family input helps, it's subjective and incomplete without direct observation, as they may misinterpret or miss cues. Choice D, ignoring subtle cues, is negligent, as these are critical indicators in the absence of speech. Choice B is the best approach, aligning with nursing skills in nonverbal communication, ensuring a holistic comfort assessment by interpreting physical signs alongside vital signs or context, vital for tailoring care to silent patients' needs.