ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
. A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?
Correct Answer: C
Rationale: Addison's disease, also known as adrenocortical insufficiency, is characterized by a deficiency in adrenal cortex hormones, particularly glucocorticoids and mineralocorticoids. One of the characteristic findings in Addison's disease is hyperkalemia, which is an elevated serum potassium level. This is due to the lack of aldosterone production by the adrenal glands, leading to decreased potassium excretion by the kidneys. Therefore, a serum potassium level of 5.8 mEq/L would best support a diagnosis of Addison's disease among the given laboratory test results.
Question 2 of 5
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
Correct Answer: C
Rationale: It is important for the nurse to instruct the client that they may not be able to use desmopressin nasally if they have nasal discharge or blockage. This is because nasal absorption is critical for the effectiveness of desmopressin, and any nasal issues may hinder proper absorption. If the client experiences nasal discharge or blockage, an alternative route for administering desmopressin may need to be considered, such as oral or injectable forms. This instruction is essential to ensure the client receives the medication effectively and manages their condition appropriately.
Question 3 of 5
The initial neurological symptom of Guilain-Barre Syndrome is:
Correct Answer: B
Rationale: The initial neurological symptom of Guillain-Barre Syndrome (GBS) is typically paresthesia, which is a tingling or numbness sensation in the legs. GBS is an autoimmune disorder that affects the peripheral nervous system, leading to muscle weakness and paralysis. As the condition progresses, symptoms may worsen and may include absent tendon reflexes, weakness in the arms and legs, and difficulty breathing. However, paresthesia is often one of the earliest and most common symptoms of GBS.
Question 4 of 5
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct initial action in this scenario would be to roll Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available. This position is known as the recovery position, and it is important for individuals who have suspected spinal injuries. By rolling Mr. Gabatan onto his abdomen, it helps protect his spine and prevent further injury. Placing a pad under his head provides some support, and covering him with material helps to keep him warm and comfortable while waiting for additional help to arrive. It is crucial to avoid movement, especially if there is a suspected spinal injury, as moving the individual incorrectly can worsen the injury and lead to permanent damage.
Question 5 of 5
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
Correct Answer: B
Rationale: Decorticate posturing is characterized by flexion of elbows, wrists, and fingers; extension of elbows and knees; plantar flexion of the feet. This type of posturing typically indicates severe damage to the cerebral hemispheres or impairment of the corticospinal tract. When a client with increased intracranial pressure (ICP) displays decorticate posturing, it suggests significant brain injury and dysfunction. This abnormal posturing is a classic sign that requires immediate medical attention and intervention.