ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 of 5
A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Protect cornea with lubricant and eye shields. In Guillain-Barre syndrome, paralysis of all extremities can lead to impaired blinking reflex, which puts the client at risk for corneal damage due to inadequate eye protection. By protecting the cornea with lubricant and eye shields, the nurse can prevent corneal abrasions and exposure keratitis, which can occur due to the inability to blink. Option B) Administer artificial tears every hour is incorrect because simply administering artificial tears does not address the need for protecting the cornea from damage. Option C) Encouraging the client to blink every 10 minutes is incorrect as the client's paralysis may prevent them from being able to blink voluntarily. Option D) Keeping the client's eyes closed with adhesive tape is incorrect because this can lead to further complications such as corneal abrasions and discomfort. Educational context: Understanding the importance of eye care in patients with Guillain-Barre syndrome is crucial for nursing care. By protecting the cornea with lubricant and eye shields, nurses can prevent serious eye complications and promote the overall well-being of the patient. This scenario highlights the need for vigilant assessment and proactive interventions to prevent potential complications in critically ill patients.
Question 2 of 5
A client tells the nurse that her biopsy results indicate that the cancer cells are well-differentiated. How should the nurse respond?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Ask the client if the healthcare provider has given her any information about the classification of her cancer. Explanation: 1. Option A is correct because it demonstrates therapeutic communication by encouraging the client to seek clarification from her healthcare provider. This empowers the client to better understand her condition and treatment options. 2. Option B is incorrect because stating that well-differentiated cancer cells usually have a poor prognosis is inaccurate. Well-differentiated cells are more similar to normal cells and may indicate a less aggressive cancer type. 3. Option C is incorrect as it provides false reassurance. All cancer diagnoses should be taken seriously, and it is essential to provide accurate information and support to the client. 4. Option D is incorrect because encouraging the client to seek a second opinion without clarifying the information provided by the healthcare provider may lead to confusion and delay in necessary treatment. Educational Context: Understanding cancer cell differentiation is crucial in determining the aggressiveness and prognosis of cancer. Well-differentiated cells resemble normal cells and may indicate a less aggressive cancer type compared to poorly differentiated cells. As a nurse, it is important to facilitate open communication, provide accurate information, and support clients in seeking clarification from their healthcare providers to make informed decisions about their care.
Question 3 of 5
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
Correct Answer: A
Rationale: The highest priority intervention in this scenario is option A) Tell the client to remain in bed. This presentation of pain, edema, and redness in the calf is indicative of a potential deep vein thrombosis (DVT). By advising the client to stay in bed, we aim to limit movement that could dislodge a blood clot, potentially causing a pulmonary embolism. This intervention is crucial to prevent a life-threatening complication. Option B) Apply warm compresses is not recommended in this case as heat can increase blood flow and potentially dislodge a clot, leading to adverse outcomes. Option C) Administer pain medication as prescribed may help alleviate the discomfort but does not address the underlying issue of a potential DVT. Option D) Encouraging the client to elevate the affected leg is generally beneficial for conditions like venous insufficiency but is not the most critical intervention when DVT is suspected. In an educational context, understanding the priority interventions for different conditions is vital for nurses to provide safe and effective care to patients. Recognizing the signs and symptoms of DVT and knowing the appropriate actions to take can prevent serious complications and improve patient outcomes.
Question 4 of 5
A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Correct Answer: A
Rationale: In the context of caring for a client with Diabetes Insipidus (DI), the most immediate intervention by the nurse is warranted by option A) Serum sodium of 185 mEq/L. This elevated serum sodium level indicates hypernatremia, which can be life-threatening in DI due to excessive water loss. Hypernatremia can lead to neurological symptoms like confusion, seizures, and coma, requiring urgent correction to prevent serious complications like brain damage. Option B) Urine output of 3000 mL per hour is a common manifestation of DI but does not pose an immediate threat as hypernatremia does. Monitoring and managing fluid balance are crucial, but the urgency lies in correcting the electrolyte imbalance first. Option C) Blood pressure of 90/60 mmHg is low but not as immediately critical as managing the electrolyte imbalance. It may be related to dehydration from DI but can be addressed once the serum sodium is stabilized. Option D) Potassium level of 4.5 mEq/L is within the normal range and is not an immediate concern in this scenario. While potassium balance is important, addressing hypernatremia takes precedence. Educationally, understanding the prioritization of interventions based on the urgency of the client's condition is crucial in nursing practice. This scenario highlights the need for nurses to recognize and respond promptly to critical electrolyte imbalances to prevent serious complications and ensure client safety.
Question 5 of 5
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
Correct Answer: B
Rationale: In assessing a client with ulcers on the lower extremity, findings that indicate venous ulcers over arterial ulcers are irregular ulcer shapes and severe edema. Venous ulcers tend to have irregular shapes due to the underlying venous hypertension, while arterial ulcers are typically more uniform in shape. Severe edema is also more characteristic of venous insufficiency, as impaired venous return leads to fluid accumulation in the tissues. Option A, black ulcers and dependent rubor, are more indicative of arterial ulcers. Black ulcers suggest ischemia and necrosis, while dependent rubor is a sign of arterial insufficiency. Option C, absent pedal pulses and shiny skin, are also more indicative of arterial ulcers, as impaired arterial blood flow leads to diminished pulses and shiny, atrophic skin. Option D, hairless lower extremities and cool feet, can be seen in both arterial and venous insufficiency, but are not as specific to venous ulcers as irregular ulcer shapes and severe edema. Educationally, understanding the differences in presentation between venous and arterial ulcers is crucial for nurses caring for patients with cardiovascular disorders. Recognizing these differences can guide appropriate interventions and help prevent complications associated with mismanagement of these conditions.