ATI RN
Client Comfort and End of Life Care ATI Questions
Question 1 of 5
Which intervention is an example of primary prevention?
Correct Answer: B
Rationale: Primary prevention focuses on preventing health issues before they occur, such as through immunizations or health education. Administering a measles, mumps, and rubella (MMR) immunization to an infant (Choice B) is a classic example of primary prevention because it protects against diseases before exposure. In contrast, administering digoxin (Choice A) is a treatment for an existing condition (heart failure), making it tertiary prevention aimed at managing or reducing complications. Obtaining a Papanicolaou smear (Choice C) is secondary prevention, as it involves early detection of cervical cancer rather than preventing it outright. Similarly, using occupational therapy for arthritis (Choice D) is tertiary prevention, helping a patient manage an existing condition rather than preventing its onset. The distinction lies in the timing and intent: primary prevention occurs before any disease process begins, and the MMR vaccine fits this definition perfectly by building immunity proactively. Thus, Choice B is correct, aligning with the goal of stopping health problems at their root.
Question 2 of 5
Using Abraham Maslow's hierarchy of human needs, a nurse assigns highest priority to which client need?
Correct Answer: B
Rationale: Maslow's hierarchy ranks human needs in five levels: physiological (base), safety, belonging, esteem, and self-actualization. Physiological needsair, water, food, shelter, and elimination (Choice B)are foundational, as survival depends on them. Elimination, encompassing urination and defecation, is critical; its impairment (e.g., urinary retention) can cause immediate harm like infection or organ damage. Security (Choice A) and safety (Choice C) are second-level needs, addressing stability and protection, but they're irrelevant if physiological needs aren't mete.g., a client can't feel safe if they can't breathe or eliminate waste. Belonging (Choice D), a third-level need, involves relationships, which are secondary to survival. For example, a postoperative client with a blocked catheter faces a life-threatening physiological crisis, trumping safety or social needs. Nurses prioritize based on this hierarchy, making elimination (Choice B) the highest priority and correct answer.
Question 3 of 5
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
Correct Answer: B
Rationale: Team ineffectiveness despite individual competence often stems from poor group dynamics, with unexpected feelings and emotions among staff (Choice B) being the usual culprit. Emotions like mistrust, resentment, or unresolved conflict disrupt communication and collaboratione.g., a nurse feeling undervalued might withhold input. Unhappiness about leadership change (Choice A) could contribute but isn't universal; new leaders can inspire if communication is strong. Fatigue from overwork (Choice C) reduces productivity but typically affects individuals uniformly, not just teamwork. Failure to involve staff in decisions (Choice D) is a factor, but emotions underlie its impacte.g., feeling ignored breeds frustration. Research (e.g., Tuckman's group development) shows emotional undercurrents derail forming cohesive teams. Addressing feelings via open forums or team-building restores function, making Choice B the correct and most common reason.
Question 4 of 5
A nurse is caring for a patient who is sleeping for abnormally long periods of time. This condition may be caused by injury to which of the following body structures?
Correct Answer: C
Rationale: Excessive sleep, or hypersomnia, often stems from central nervous system dysfunction, particularly the hypothalamus , which regulates sleep-wake cycles via the suprachiasmatic nucleus (SCN) and orexin neurons. Injury heree.g., from trauma or tumordisrupts circadian rhythm and arousal, causing prolonged sleep, as seen in conditions like narcolepsy or post-traumatic hypersomnia. The spinal cord conducts signals but doesn't control sleep; injury might cause paralysis, not hypersomnia. The pancreas manages glucose, and while hypoglycemia can induce fatigue, it doesn't directly govern sleep duration. The thyroid influences metabolism; hypothyroidism causes lethargy, but not abnormally long sleep periods distinct from fatigue. For example, a hypothalamic lesion might reduce orexin, a wake-promoting neurotransmitter, leading to 16-hour sleep days versus a normal 7-9. Nursing assessments would note this brain region's role in sleep homeostasis, per Taylor's text, confirming Choice C as the correct answer.
Question 5 of 5
A patient who previously was a smoker has recently stopped smoking but reports having a lot of trouble sleeping at night. How would the nurse respond?
Correct Answer: C
Rationale: Nicotine withdrawal disrupts sleep due to its stimulant loss, but this resolves. 'Sleep problems from stopping smoking are temporary' is correct; insomnia peaks 1-3 weeks post-cessatione.g., nicotine's absence drops arousal, yet cravings wake patientsbut normalizes within months, per sleep research. Choice A, 'decide what's more important,' dismisses the patient's struggle, lacking empathy. Choice B, 'it might be better to smoke,' undermines cessation's health benefits (e.g., reduced cancer risk) and contradicts nursing ethics. Choice D, 'this will always be a problem,' is false; chronic insomnia isn't inevitable post-smokinge.g., most ex-smokers sleep normally by 6 months. A nurse, per Taylor, reassures with evidencee.g., 'Your brain's adjusting, it'll pass'promoting resilience. Choice C is the supportive, accurate response.