ATI RN
Pediatrics Baby Fell off Bed Questions Questions
Question 1 of 5
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale: The most important assessment for the nurse to make first in this situation is the client's blood pressure. Abrupt discontinuation of prednisone, especially in a client with lupus erythematosus, can lead to adrenal insufficiency or an Addisonian crisis. Addisonian crisis can present with symptoms such as severe hypotension, fatigue, weakness, and even shock. Therefore, monitoring the client's blood pressure is crucial to assess for signs of adrenal insufficiency and to intervene promptly if needed. Once blood pressure is assessed, the nurse can then proceed to assess other parameters such as breath sounds, capillary refill, and the presence of a butterfly rash.
Question 2 of 5
A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?
Correct Answer: D
Rationale: The first action should be to flush the eye continuously with a sterile solution to remove the chemical and prevent further damage to the eye. This is important in cases of chemical burns to prevent the chemical from causing more harm or spreading to other parts of the eye. It is crucial to start immediate irrigation to promote the best possible outcome and help alleviate the pain and potential long-term damage. Once the eye has been thoroughly flushed, further assessment and appropriate treatment can be provided by the healthcare team.
Question 3 of 5
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
Correct Answer: B
Rationale: Mr. Boy, who suffered severe flame burns from smoking in bed, would require specialized care in a burn unit. In such units, patients like Mr. Boy are typically placed in semi-private rooms. This setting allows for close monitoring, infection control, and privacy for the patient to receive specialized care. Semi-private rooms also facilitate the management of burn injuries, including wound care, dressing changes, and overall patient care. Additionally, the environment in a semi-private room helps in preventing the spread of infections and ensures that the patient's specific care needs are met effectively.
Question 4 of 5
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
Correct Answer: A
Rationale: Clients with diabetes insipidus lack antidiuretic hormone (ADH), also known as vasopressin. ADH plays a crucial role in regulating the amount of water reabsorbed by the kidneys, thus maintaining the body's water balance. In diabetes insipidus, there is a deficiency or decreased response to ADH, leading to excessive urine production and consequent dehydration if not managed properly. Therefore, understanding the role and function of ADH is essential for the nurse to include in the teaching plan for a client diagnosed with diabetes insipidus.
Question 5 of 5
For the first 72 hours thyroidectomy surgery, the nurse would assess the client for Chvostek's sign and Trousseau's sign because they indicate which of the following?
Correct Answer: A
Rationale: In the context of pharmacology and pediatric care, understanding the significance of Chvostek's sign and Trousseau's sign post-thyroidectomy surgery is crucial. These signs are indicative of hypocalcemia, which is characterized by low levels of calcium in the blood. Chvostek's sign is elicited by tapping the facial nerve in the region of the parotid gland, resulting in facial muscle twitching. Trousseau's sign involves inflating a blood pressure cuff on the arm, leading to carpal spasm. Both signs suggest neuromuscular irritability, which is a classic manifestation of low calcium levels. Option A, hypocalcemia, is the correct answer because Chvostek's and Trousseau's signs are specific to this condition. Hypokalemia (Option B) is characterized by low potassium levels, while hypercalcemia (Option C) is the opposite of what these signs indicate. Hyperkalemia (Option D) refers to elevated potassium levels and is not related to the signs mentioned. Educationally, by understanding the association between these signs and hypocalcemia, nurses and healthcare providers can promptly recognize and intervene in cases of post-thyroidectomy hypocalcemia, thereby preventing potential complications such as tetany or seizures in pediatric patients. This knowledge underscores the importance of thorough assessment and monitoring in the postoperative period, enhancing patient safety and outcomes.