ATI RN
Pediatric Nursing Cardiovascular Disorders Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The family suspects that AIDS dementia is occurring in their son who is HIV positive. Which symptom confirms their suspicions?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) A change has recently occurred in his handwriting. This symptom suggests AIDS dementia because it is a common neurological manifestation of advanced HIV infection in pediatric patients. AIDS dementia complex can present with cognitive impairment, behavioral changes, motor dysfunction, and alterations in handwriting, which may include deterioration in fine motor skills. Option B) The client has a persistent cough and fever is incorrect because these symptoms are more indicative of respiratory infections common in HIV-positive pediatric patients, such as pneumonia or tuberculosis, rather than AIDS dementia. Option C) The client experiences shortness of breath is incorrect as it could be a sign of respiratory issues or cardiovascular problems in the context of HIV, but it is not specific to AIDS dementia. Option D) The client exhibits a loss of appetite is also incorrect since it is a non-specific symptom commonly seen in various conditions, including HIV infection, but not specifically indicative of AIDS dementia. Educationally, understanding the neurological manifestations of advanced HIV infection, such as AIDS dementia complex, is crucial for pediatric nurses caring for HIV-positive children. Recognizing subtle changes in handwriting can prompt early intervention and appropriate management to improve the quality of life for these patients. Regular neurological assessments and education for families on recognizing such symptoms are essential in the holistic care of pediatric patients with HIV.
Question 5 of 5
The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever. The nurse knows that which laboratory study would assist in confirming the diagnosis?
Correct Answer: D
Rationale: In the context of pediatric nursing and cardiovascular disorders, understanding the laboratory studies that assist in confirming a diagnosis like rheumatic fever is crucial for providing effective care. The correct answer is D) Anti-streptolysin O titer. Rheumatic fever is often preceded by a streptococcal infection, and the presence of anti-streptolysin O antibodies indicates recent streptococcal infection, helping confirm the diagnosis. This test is specific to streptococcal infections and is essential in diagnosing rheumatic fever accurately. Option A) Immunoglobulin is too broad and does not specifically target the streptococcal infection needed for diagnosing rheumatic fever. Option B) Red blood cell count and C) White blood cell count are general tests that do not provide specific information about a streptococcal infection or rheumatic fever. Educationally, understanding the rationale behind each laboratory test in diagnosing specific conditions enhances a nurse's ability to provide comprehensive care to pediatric patients with cardiovascular disorders like rheumatic fever. Knowing which tests are appropriate for specific conditions can lead to timely diagnosis and appropriate treatment interventions.