ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.
Question 2 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 3 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 4 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.
Question 5 of 5
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
Correct Answer: A
Rationale: When a patient is placed on seizure precautions, obtaining oral temperature would be contraindicated. This is because sticking a thermometer in the mouth may pose a risk during a seizure episode, as the patient might bite down on it and cause injury. It is important to prioritize safety measures to minimize the risk of harm to the patient. Other methods of monitoring temperature, such as using a tympanic thermometer or a forehead thermometer, would be more appropriate in this situation.