ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 of 5
A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
Correct Answer: C
Rationale: The sudden severe headache and nasal congestion in a client with a spinal cord injury at the level of T3, along with flushed skin, goose bumps, and potentially increased blood pressure due to autonomic dysreflexia. This is a medical emergency that requires immediate intervention from a healthcare provider. Calling the physician ensures prompt assessment and treatment to prevent further complications associated with autonomic dysreflexia, such as hypertensive crisis, seizures, or stroke. It is important to address this situation promptly to prevent any serious consequences for the client's health.
Question 2 of 5
Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson's or Huntington's diseases, or even epilepsy?
Correct Answer: A
Rationale: Emotional counseling and helping with common daily activities are important nursing care interventions for clients with neurologic diseases such as Parkinson's, Huntington's, and epilepsy because these clients often experience depression, anxiety, and difficulty performing basic self-care tasks. These diseases can have a significant impact on the client's mental health, leading to feelings of helplessness and loss of independence. Providing emotional support and assistance with daily activities can help improve the client's overall well-being and quality of life. Additionally, these interventions can also help prevent complications such as complications such as pressure sores, infections, and malnutrition that may arise from the inability to perform self-care tasks independently.
Question 3 of 5
The client is taking phenyton (Dilantin) for seizure control. A sample is drawn to determine the serum drug level, and the nurse reviews the results. Which of the following would indicate a therapeutic serum drug range?
Correct Answer: A
Rationale: The therapeutic serum drug range for phenytoin (Dilantin) is typically considered to be 10 to 20 mcg/ml. However, some sources may cite a broader range of 5 to 20 mcg/ml. Therefore, a serum drug level range of 5 to 10 mcg/ml would fall within the acceptable therapeutic range for phenytoin. Serum levels outside of this range may indicate potential toxicity (above range) or subtherapeutic levels (below range) which could result in inadequate seizure control.
Question 4 of 5
Which of the following would the nurse use to document a finding that the patient's ear is draining?
Correct Answer: A
Rationale: Otorrhea is the medical term used to describe drainage from the ear. It is a finding that indicates the ear is draining fluid, which can be a sign of infection or other underlying issues. Otalgia refers to ear pain, ototoxic refers to substances that can damage the ear, and tinnitus refers to ringing in the ears. Therefore, otorrhea is the most appropriate term to document the finding of a draining ear.
Question 5 of 5
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
Correct Answer: B
Rationale: Dilated pupils can cause increased sensitivity to light, leading to discomfort or visual disturbances. Wearing sunglasses can help protect the eyes from bright light and reduce potential discomfort for the patient. This safety instruction is important to promote the patient's comfort and prevent any potential harm due to light sensitivity.