ATI RN
Pediatric Nursing Cardiovascular Disorders Questions
Question 1 of 5
A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to implement is to review the client's most recent thyroid function test results (Option A). This is the most appropriate course of action because the client's difficulty falling asleep and feelings of depression may be attributed to their hypothyroidism. By reviewing the thyroid function test results, the nurse can assess the client's thyroid hormone levels and determine if they are within the therapeutic range. If the levels are suboptimal, adjustments to the client's thyroid replacement therapy may be necessary to address their symptoms. Option B, encouraging the client to take an afternoon nap, is not the most appropriate action in this case as it does not address the underlying cause of the client's sleep difficulties and depression. While adequate rest is important, simply taking a nap does not address the potential thyroid-related issues contributing to the client's symptoms. Referring the client for a psychiatric evaluation (Option C) is not the initial step to take in this situation. It is important to first assess and address any physiological factors, such as thyroid function, that may be contributing to the client's symptoms before considering psychiatric evaluation. Suggesting reducing fluid intake before bedtime (Option D) is not relevant to the client's reported symptoms of difficulty falling asleep due to depression in the context of hypothyroidism. While good sleep hygiene practices are important, they are not the primary intervention needed in this case. Educationally, this question highlights the importance of holistic nursing care and the need to consider underlying physiological factors when addressing symptoms in clients with chronic conditions like hypothyroidism. It also emphasizes the significance of thorough assessment and using diagnostic results to guide nursing interventions.
Question 2 of 5
A female client who was involved in a motor vehicle collision with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A
Rationale: In this scenario, option A is the correct intervention for the nurse to implement. Monitoring the left leg for pain, pallor, paresthesia, paralysis, and pressure is crucial in assessing neurovascular status. Verifying pedal pulses using a Doppler pulse device helps determine blood flow to the foot, which is essential in assessing circulation. Evaluating the application of the splint ensures that it is not causing any compromise to circulation. Option B, only verifying pedal pulses, is not comprehensive enough to assess the client's condition fully. Option C, evaluating the splint alone, does not address the need to assess for other signs of neurovascular compromise. Option D, administering pain medication, does not address the immediate need to assess and address potential circulation issues that could lead to serious complications like compartment syndrome. In an educational context, understanding the importance of neurovascular assessments in clients with immobilized limbs is crucial for nurses caring for orthopedic patients. This scenario highlights the significance of comprehensive assessments and prompt interventions to prevent potential complications related to impaired circulation. Nurses must be able to recognize signs of neurovascular compromise and take appropriate actions to ensure patient safety and optimal outcomes.
Question 3 of 5
A male client with pernicious anemia takes supplemental folate and self-administers monthly Vitamin B12 injections. He reports feeling increasingly fatigued. Which laboratory value should the nurse review?
Correct Answer: A
Rationale: In this scenario, the nurse should review the complete blood count (CBC) of the client. Pernicious anemia is primarily caused by a deficiency in Vitamin B12, which can lead to megaloblastic anemia characterized by enlarged and immature red blood cells. Folate supplementation can mask the anemia associated with Vitamin B12 deficiency, but it does not address the neurological symptoms that can occur. Reviewing the CBC will provide information on the client's red blood cell count, hemoglobin levels, and mean corpuscular volume, which can indicate whether the anemia is improving or worsening despite the Vitamin B12 injections. An increase in fatigue could be a sign of worsening anemia, so monitoring the CBC is crucial in this case. The other options are not directly related to the management of pernicious anemia. Serum ferritin levels are more indicative of iron stores in the body, not Vitamin B12 levels. Serum potassium levels are important in conditions affecting electrolyte balance, which is not the primary concern in this case. Liver function tests are not typically affected by pernicious anemia unless there are other underlying liver conditions present. Understanding the importance of monitoring specific laboratory values in patients with different conditions is crucial in nursing practice, especially in pediatric patients who may present with atypical symptoms or complications. Regular monitoring and assessment help in early detection of complications and timely intervention, ensuring optimal patient outcomes.
Question 4 of 5
A female client who received partial-thickness and full-thickness burns over 40% of her body in a house fire is admitted to the inpatient burn unit. What fluid should the nurse prepare to administer during the acute phase of the client's burn recovery?
Correct Answer: A
Rationale: In the acute phase of burn recovery, fluid resuscitation is critical to maintain adequate tissue perfusion and prevent complications like hypovolemic shock. The correct fluid to administer in this scenario is Ringer's Lactate. Ringer's Lactate is preferred due to its composition containing electrolytes (sodium, potassium, calcium) that closely resemble those lost in burn injuries, helping to restore intravascular volume and electrolyte balance. Normal saline (Option B) is isotonic and lacks the electrolyte composition found in Ringer's Lactate, which may not adequately address the electrolyte imbalances seen in burn patients. Dextrose 5% in water (D5W - Option C) is a hypotonic solution that primarily provides free water without addressing the electrolyte needs in burn patients. Hypertonic saline (Option D) is not typically used in the initial resuscitation phase of burn patients and may lead to further electrolyte imbalances. Educationally, understanding the rationale behind fluid choices in burn patients is crucial for nurses caring for these patients. By grasping the principles of fluid resuscitation in burn injuries, nurses can provide optimal care to ensure positive outcomes and prevent complications in this vulnerable population.
Question 5 of 5
A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose of Humulin N insulin at 0800. At 1600, the client complains of diaphoresis, rapid heartbeat, and feeling shaky. What should the nurse do first?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take first is to determine the client's current glucose level (Option A). This is crucial in assessing the client's condition and identifying if the symptoms of diaphoresis, rapid heartbeat, and feeling shaky are related to hypoglycemia, a common adverse effect of insulin therapy. Option B, administering 10 units of fast-acting insulin, is incorrect as it can further lower the client's blood glucose levels, exacerbating the symptoms of hypoglycemia. Option C, offering a snack with high protein, is not the first priority as assessing the glucose level is necessary to determine the appropriate intervention. Option D, increasing the IV infusion rate of normal saline, is not indicated for addressing hypoglycemia associated with insulin therapy. Educationally, this scenario highlights the importance of prompt assessment and intervention in managing potential complications of insulin therapy in diabetic patients. Nurses need to prioritize assessing the client's glucose levels to guide appropriate interventions and prevent further complications. Understanding the signs and symptoms of hypoglycemia and the appropriate nursing actions is essential in providing safe and effective care to patients with diabetes.