ATI RN
Pediatric Nursing Cardiovascular Disorders Questions
Question 1 of 5
A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Pain. The probable etiology of the male client's difficulty sleeping is pain caused by Herpes zoster (shingles) lesions on his thorax. Pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. This pain can disrupt the client's ability to fall asleep or stay asleep, leading to sleep disturbances. Option B) Nocturia, which is excessive urination at night, is not likely to be the cause of the client's sleep difficulty in this case. Option C) Dyspnea, which is difficulty breathing, and Option D) Frequent cough are also not relevant to the client's complaint of difficulty sleeping due to shingles-related pain. Educationally, understanding the impact of pain on sleep is crucial for nurses caring for clients with conditions like Herpes zoster. Nurses need to assess and manage pain effectively to promote quality sleep, which is essential for the client's overall well-being and recovery. By recognizing pain as a potential barrier to sleep, nurses can implement appropriate interventions to improve the client's comfort and rest.
Question 2 of 5
A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to implement is to select option B: Obtain a specimen of urethral drainage for culture. This is the most appropriate initial action as the client is presenting with symptoms suggestive of a possible urinary tract infection (UTI) or a sexually transmitted infection (STI) following unprotected sexual intercourse. By obtaining a specimen for culture, the nurse can identify the causative organism and guide appropriate treatment. Option A, observing the perineal area for a chancroid-like lesion, is incorrect because the client's symptoms do not specifically suggest the presence of a chancroid lesion, and obtaining a urethral culture is a more direct way to diagnose a possible infection. Option C, assessing for perineal itching, erythema, and excoriation, while relevant, does not address the need for a definitive diagnosis through a urethral culture. Option D, identifying all sexual partners in the last four days, is important for contact tracing and counseling but is not the immediate priority in this situation. From an educational standpoint, this question highlights the importance of thorough assessment and appropriate interventions in clients presenting with genitourinary symptoms following sexual activity. It emphasizes the need for nurses to consider both UTIs and STIs in the differential diagnosis and to prioritize diagnostic testing to guide treatment decisions effectively.
Question 3 of 5
During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take is to continue to monitor the fluid output (Option C). This is the most appropriate response because after a paracentesis, it is essential to monitor the drainage output to assess the client's response to the procedure and to watch for any signs of complications. Option A, palpating for abdominal distention, is not the priority in this situation as monitoring fluid output takes precedence to ensure proper drainage and assess for complications. Option B, sending the fluid to the lab for analysis, may be necessary at some point, but the immediate action should be to monitor the fluid output to ensure proper drainage and assess for any immediate concerns. Option D, clamping the drainage tube for 5 minutes, is not recommended as it may lead to a potential buildup of fluid in the abdomen, which could result in discomfort and complications for the client. From an educational standpoint, understanding the importance of monitoring post-procedural drainage output is crucial in pediatric nursing, especially in cases like ascites where fluid removal plays a significant role in managing the client's condition. Nurses must prioritize ongoing assessment and monitoring to ensure optimal patient outcomes and prevent potential complications.
Question 4 of 5
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
Correct Answer: B
Rationale: In this scenario, option B, Carotid bruit, is the correct answer indicating a client at risk for a brain attack (stroke). A carotid bruit is an abnormal sound heard when auscultating the carotid artery, which can indicate turbulent blood flow due to atherosclerosis, a major risk factor for stroke. This finding is significant because it suggests potential narrowing or blockage of the carotid artery, increasing the risk of emboli formation and subsequent stroke. Option A, nuchal rigidity, is associated with meningitis, not specifically with an increased risk for stroke. Option C, jugular vein distention, is more related to cardiovascular conditions like heart failure, not a direct indicator of stroke risk. Option D, palpable cervical lymph node, is more indicative of a localized infection or inflammation, not directly linked to stroke risk assessment. In an educational context, understanding these assessment findings and their significance in differentiating between various health conditions is crucial for pediatric nurses caring for patients with cardiovascular disorders. Being able to recognize these signs accurately can lead to timely interventions and prevention strategies, ultimately improving patient outcomes.
Question 5 of 5
The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide?
Correct Answer: A
Rationale: The correct answer is A) Invite friends over regularly to share in meal times. This option is the best choice because it addresses a potential psychosocial factor contributing to the weight loss of the client with Parkinson's disease. Parkinson's disease can lead to social isolation, depression, and decreased appetite, which can all contribute to weight loss. By inviting friends over for meals, the client is more likely to have social interaction, which can improve mood and appetite. Option B) Encouraging the client to drink clear liquids between meals does not directly address the underlying issue of weight loss in Parkinson's disease. While hydration is important, it does not specifically target the potential causes of weight loss in this case. Option C) Coaching the client to make an intentional effort to swallow is not the most appropriate response as it assumes the weight loss is solely due to swallowing difficulties, which may not be the case for this client. Option D) Talking to the healthcare provider about prescribing an appetite stimulant should be considered if other interventions do not work; however, it should not be the first line of action. Encouraging social interaction and a supportive environment during meals can be more effective in addressing weight loss in this situation. In an educational context, understanding the multifactorial nature of weight loss in clients with Parkinson's disease is crucial for nurses caring for these individuals. Providing holistic care that addresses not only physical symptoms but also psychosocial aspects can lead to better outcomes for the client.