ATI RN
Pediatric Nursing Cardiovascular Disorders Questions
Question 1 of 5
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
Correct Answer: D
Rationale: In this scenario, the most immediate action by the nurse should be prompted by the further decline in the level of consciousness (Option D). This is crucial because a worsening level of consciousness can indicate a deterioration in the client's condition, potentially leading to life-threatening complications. In pediatric patients, changes in mental status are critical indicators of systemic compromise and require immediate attention to prevent adverse outcomes. Option A, facial puffiness and periorbital edema, are common symptoms of hypothyroidism and may not require immediate action unless severe or accompanied by other concerning signs. Option B, a hematocrit of 30%, while low, may not be the most immediate concern compared to a declining level of consciousness. It could indicate anemia, which should be addressed but is not as urgent as a neurological deterioration. Option C, cold and dry skin, is also a symptom of hypothyroidism and may not warrant immediate action unless it is severe and contributing to the decline in the client's condition. In an educational context, understanding the prioritization of assessments and interventions based on the urgency of the client's condition is vital in pediatric nursing. This case highlights the importance of recognizing changes in consciousness as a red flag requiring immediate attention to prevent further deterioration and ensure optimal patient outcomes.
Question 2 of 5
While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C: "Observe for prolonged periods of apnea." The nurse's first priority during a seizure is to ensure the client's airway remains clear and that they are breathing adequately. Prolonged periods of apnea can lead to hypoxia, which can be life-threatening. By closely monitoring the client's breathing, the nurse can intervene promptly if respiratory distress occurs. Option A, documenting details of the seizure activity, is important for the client's medical record but is not the most immediate concern during an active seizure. Option B, observing for lacerations to the tongue, is important post-seizure to assess for injuries but is not the priority during the seizure itself. Option D, evaluating for evidence of incontinence, is also a secondary concern compared to ensuring the client's airway and breathing are stable. In an educational context, this question highlights the critical importance of prioritizing interventions during a medical emergency like a seizure. Nurses must be prepared to act quickly and decisively to ensure the safety and well-being of their clients, especially when faced with unexpected situations. Understanding the priorities of care during a seizure is crucial knowledge for nurses working in various healthcare settings, including pediatric nursing where seizures can occur.
Question 3 of 5
A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to implement is to select option B: Obtain a specimen of urethral drainage for culture. This is the most appropriate initial action as the client is presenting with symptoms suggestive of a possible urinary tract infection (UTI) or a sexually transmitted infection (STI) following unprotected sexual intercourse. By obtaining a specimen for culture, the nurse can identify the causative organism and guide appropriate treatment. Option A, observing the perineal area for a chancroid-like lesion, is incorrect because the client's symptoms do not specifically suggest the presence of a chancroid lesion, and obtaining a urethral culture is a more direct way to diagnose a possible infection. Option C, assessing for perineal itching, erythema, and excoriation, while relevant, does not address the need for a definitive diagnosis through a urethral culture. Option D, identifying all sexual partners in the last four days, is important for contact tracing and counseling but is not the immediate priority in this situation. From an educational standpoint, this question highlights the importance of thorough assessment and appropriate interventions in clients presenting with genitourinary symptoms following sexual activity. It emphasizes the need for nurses to consider both UTIs and STIs in the differential diagnosis and to prioritize diagnostic testing to guide treatment decisions effectively.
Question 4 of 5
During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take is to continue to monitor the fluid output (Option C). This is the most appropriate response because after a paracentesis, it is essential to monitor the drainage output to assess the client's response to the procedure and to watch for any signs of complications. Option A, palpating for abdominal distention, is not the priority in this situation as monitoring fluid output takes precedence to ensure proper drainage and assess for complications. Option B, sending the fluid to the lab for analysis, may be necessary at some point, but the immediate action should be to monitor the fluid output to ensure proper drainage and assess for any immediate concerns. Option D, clamping the drainage tube for 5 minutes, is not recommended as it may lead to a potential buildup of fluid in the abdomen, which could result in discomfort and complications for the client. From an educational standpoint, understanding the importance of monitoring post-procedural drainage output is crucial in pediatric nursing, especially in cases like ascites where fluid removal plays a significant role in managing the client's condition. Nurses must prioritize ongoing assessment and monitoring to ensure optimal patient outcomes and prevent potential complications.
Question 5 of 5
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
Correct Answer: B
Rationale: In this scenario, option B, Carotid bruit, is the correct answer indicating a client at risk for a brain attack (stroke). A carotid bruit is an abnormal sound heard when auscultating the carotid artery, which can indicate turbulent blood flow due to atherosclerosis, a major risk factor for stroke. This finding is significant because it suggests potential narrowing or blockage of the carotid artery, increasing the risk of emboli formation and subsequent stroke. Option A, nuchal rigidity, is associated with meningitis, not specifically with an increased risk for stroke. Option C, jugular vein distention, is more related to cardiovascular conditions like heart failure, not a direct indicator of stroke risk. Option D, palpable cervical lymph node, is more indicative of a localized infection or inflammation, not directly linked to stroke risk assessment. In an educational context, understanding these assessment findings and their significance in differentiating between various health conditions is crucial for pediatric nurses caring for patients with cardiovascular disorders. Being able to recognize these signs accurately can lead to timely interventions and prevention strategies, ultimately improving patient outcomes.