ATI RN
Client Comfort Questions
Question 1 of 5
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?
Correct Answer: B
Rationale: The nursing process is a systematic framework with five steps: assessment, nursing diagnosis, planning, implementation, and evaluation. The nursing diagnosis step (Choice B) is where the nurse analyzes data collected during assessment to identify the patient's responses to actual or potential health problems, such as 'Risk for Infection' or 'Acute Pain.' Assessment (Choice A) involves gathering subjective and objective data (e.g., vital signs, patient history), but it doesn't involve interpreting those findings into specific responsesthat happens in the nursing diagnosis phase. Planning (Choice C) follows, where the nurse sets goals and interventions based on the diagnosis, while evaluation (Choice D) assesses whether those goals were met. For example, if a patient reports pain and the nurse notes a fever, the nursing diagnosis might be 'Acute Pain related to inflammation,' a conclusion drawn only after assessment data is analyzed. Thus, identifying responseswhether current or at-riskoccurs distinctly in the nursing diagnosis step, making Choice B the correct answer.
Question 2 of 5
Nurse Cay inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has:
Correct Answer: C
Rationale: Small hemorrhagic spots on the skin are petechiae (Choice C), pinpoint, non-blanching red or purple marks caused by capillary bleeding under the skin. They indicate conditions like thrombocytopenia, vasculitis, or infection (e.g., meningitis), requiring prompt investigation. Extravasation (Choice A) is fluid leakage into tissues, typically from IV infiltration, not hemorrhagic spots. Osteomalacia (Choice B) is bone softening from vitamin D deficiency, unrelated to skin findings. Uremia (Choice D), excess urea in blood from kidney failure, may cause pruritus or pallor, not petechiae specifically. For example, petechiae in a client with low platelets (e.g., 20,000/µL) signal bleeding risk, distinct from extravasation's swelling or uremia's systemic symptoms. Accurate documentation as petechiae guides diagnosis and treatment, making Choice C the correct term.
Question 3 of 5
Nurse Berri inspects a client's pupil size and determines that it's 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
Correct Answer: A
Rationale: Unequal pupil sizes2 mm left, 3 mm rightare termed anisocoria (Choice A), a condition where one pupil differs from the other by more than 1 mm. It can be benign (e.g., physiological anisocoria in 20% of people) or signal pathology like nerve damage or brain injury, requiring further assessment. Ataxia (Choice B) is uncoordinated movement, unrelated to pupils. Cataract (Choice C) is lens opacity causing blurred vision, not pupil asymmetry. Diplopia (Choice D) is double vision, a symptom, not a pupil finding. For example, anisocoria in trauma might indicate cranial nerve III compression, while in health it's incidental. Accurate terminology guides diagnosise.g., charting anisocoria' prompts neurological checks. Choice A correctly names this observation, making it the answer.
Question 4 of 5
A nurse teaches a young couple to put their newborn on his back to sleep. What is the rationale for this information?
Correct Answer: A
Rationale: Teaching parents to place a newborn supine (on the back) aims to reduce sudden infant death syndrome (SIDS), a leading cause of infant mortality. 'Prone position increases the risk for sudden infant death syndrome' is correct; studies (e.g., AAP guidelines since 1992's 'Back to Sleep' campaign) show prone sleeping raises SIDS risk 2-13 times, possibly via airway obstruction or rebreathing CO2-rich air. Choice B, 'prone position decreases the risk,' is false, contradicting evidence. Choice C, 'supine position may alter the size and shape of the infant's head,' notes positional plagiocephaly (flat head), but this cosmetic issue is manageable (e.g., tummy time) and less critical than SIDS. Choice D, 'supine position makes changing diapers and feeding difficult,' is impractical and unfounded; supine is standard for sleep, not care tasks. For example, SIDS rates dropped 50% post-campaign, prioritizing safety over minor concerns. Choice A reflects this life-saving rationale, making it correct.
Question 5 of 5
A patients bed partner reports the patient often has irregular snoring and silence followed by a snort. Does this warrant further assessment?
Correct Answer: C
Rationale: Irregular snoring with silence and snorts suggests a sleep disorder needing evaluation. 'Yes, this is an indicator of obstructive apnea' is correct; obstructive sleep apnea (OSA) features airway collapse, pausing breathing (apnea)e.g., 10-second silencesthen gasping snorts, per AASM criteria. Choice A, 'snoring has varied patterns,' dismisses the pattern's specificity; normal snoring lacks prolonged pauses. Choice B, 'this is normal snoring,' is false; healthy snoring is rhythmic, not interruptede.g., no 30-second gaps. Choice D, 'the bed partner is unable to sleep,' focuses on the partner, not the patient's health risk (e.g., hypoxia). OSA, linked to hypertension and fatigue, requires polysomnography, per Taylor's nursing assessment. Choice C flags this red flag correctly.