ATI RN
Pediatrics Baby Fell off Bed Questions Questions
Question 1 of 5
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client's urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?
Correct Answer: B
Rationale: Diabetes insipidus is a condition characterized by the inability of the kidneys to adequately concentrate urine, leading to excessive dilute urine production. In diabetes insipidus, both urine and serum osmolality levels are typically below normal due to the dilution of urine. When urine output suddenly rises above 200mL/hour in a client with severe head trauma, it may indicate diabetes insipidus, especially if the urine and serum osmolality levels are below normal. This abnormality in osmolality levels is due to the impaired ability of the kidneys to concentrate urine, resulting in decreased urine osmolality and subsequent dilution of the serum osmolality.
Question 2 of 5
A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:
Correct Answer: A
Rationale: Appendectomy as a treatment for acute appendicitis is classified as an emergency surgery. Acute appendicitis is considered a medical emergency that requires prompt surgical intervention to prevent complications such as a ruptured appendix, which can lead to peritonitis, a life-threatening condition. In emergency situations, surgery must be done urgently to address the immediate threat to the patient's health. This is in contrast to elective surgeries, which are typically scheduled in advance and do not require immediate attention. In the case described, the patient's symptoms of fever, nausea, vomiting, and vague abdominal pain suggest an acute presentation that necessitates urgent surgical intervention, making it an emergency appendectomy.
Question 3 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 4 of 5
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
Correct Answer: A
Rationale: Orthopnea is a common symptom of congestive heart failure. It is defined as difficulty in breathing when lying flat, which improves when sitting up or standing. This occurs due to the redistribution of blood in the body when changing positions. As fluid accumulates in the lungs in congestive heart failure, lying down increases pressure on the chest and impairs breathing. Therefore, orthopnea is a significant assessment finding that would suggest to the home health nurse that the patient is developing congestive heart failure. Fever, weight loss, and calf pain are not typically associated with congestive heart failure.
Question 5 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.