ATI RN
Client Safety Questions
Question 1 of 5
What type of document states in writing the patient's healthcare choices or wishes if the person is unable?
Correct Answer: B
Rationale: The correct answer is B: Advanced care directive. This document allows individuals to outline their healthcare preferences in the event they are unable to communicate. It provides clear instructions on the type of care they wish to receive or refuse. Verbal consent (A) is temporary and may not accurately reflect long-term preferences. Durable power of attorney (C) designates a person to make healthcare decisions, but may not include specific preferences. Comfort measures only (CMO) order (D) is a medical directive for end-of-life care, not a comprehensive document like an advanced care directive.
Question 2 of 5
A client's body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance. This process is known as:
Correct Answer: B
Rationale: The correct answer is B: homeostasis. Homeostasis refers to the body's ability to regulate internal conditions to maintain stability and balance. It involves various physiologic mechanisms such as temperature regulation, blood pressure control, and pH balance. Homeostasis is crucial for the body to function properly. A: Stress is a state of mental or emotional strain and is not the same as the body's internal balance regulation. C: Self-regulation is a broad term that can encompass various aspects of personal control and behavior, but it does not specifically refer to the body's physiological balance. D: Fight-or-flight response is a specific physiological response to perceived threats, not the overall process of maintaining internal balance.
Question 3 of 5
When assessing visual acuity of the older adult, which visual finding is associated with aging?
Correct Answer: B
Rationale: The correct answer is B: Presbyopia. Presbyopia is a common age-related condition where the eye's lens loses flexibility, leading to difficulty focusing on close objects. Myopia (choice A), nearsightedness, is not specifically associated with aging. Strabismus (choice C), misalignment of the eyes, typically develops in childhood. Astigmatism (choice D), an irregular curvature of the eye's cornea or lens, can affect people of all ages, not just older adults. Presbyopia is the most relevant choice for visual changes associated with aging due to the natural aging process affecting the eye's ability to focus on close objects.
Question 4 of 5
Upon skin inspection of an older adult, the coccyx wound is noted to be intact, reddened, and non-blanchable. What is the best way to document the nurse's assessment finding?
Correct Answer: A
Rationale: The correct way to document the nurse's assessment finding of an intact, reddened, and non-blanchable coccyx wound in an older adult is as a stage I pressure injury. A stage I pressure injury is characterized by intact skin with non-blanchable redness. In this case, the skin is intact, showing the initial signs of tissue damage due to pressure. Stages II, III, and IV pressure injuries involve more severe damage to the skin and underlying tissues. Stage II involves partial-thickness skin loss, stage III involves full-thickness skin loss, and stage IV involves full-thickness skin loss with extensive tissue necrosis. Since the coccyx wound is only showing redness without any loss of skin integrity, it aligns with a stage I pressure injury. Choices B, C, and D are incorrect as they describe more advanced stages of pressure injuries with skin breakdown, which is not present in this case.
Question 5 of 5
A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first?
Correct Answer: D
Rationale: The correct answer is D. The increase in the patient's temperature and dark urine could indicate a urinary tract infection (UTI), a common issue in older adults with indwelling catheters. The patient's confusion could be a sign of systemic infection. The RN should recommend a urine culture to confirm UTI and initiate appropriate treatment. A is incorrect because confusion in an older adult should not be dismissed without investigating the underlying cause. B is incorrect as increasing fluid intake may dilute the urine but does not address the potential infection. C is incorrect as the assessment findings are not normal and should not be ignored.