ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A nurse is preparing to accompany a medical mission's team to a third world country. Marasmus is seen frequently in children 6 months to 2 years in this country. Which symptoms should the nurse expect for this condition?
Correct Answer: A
Rationale: Marasmus is a form of severe malnutrition characterized by a significant deficiency in calories and protein intake. Symptoms of marasmus include severe wasting of muscle and fat stores, giving the appearance of loose, wrinkled skin due to the loss of subcutaneous fat. Other symptoms may include lethargy, irritability, delayed growth and development, and weakened immune function. Edematous skin is more commonly associated with kwashiorkor, another form of severe malnutrition characterized by protein deficiency with adequate caloric intake. Depigmentation of the skin and dermatoses are not typical symptoms of marasmus.
Question 2 of 5
Discharge care planning has begun for a seriously injured patient who is Asian. The patient's parents have refused routine home health visits. The pediatric nurse understands the family may:
Correct Answer: C
Rationale: In some cultures, families may prefer to handle health matters internally, viewing outside assistance as a last resort.
Question 3 of 5
Severe and extensive hemolysis causes which of the ff?
Correct Answer: B
Rationale: Severe and extensive hemolysis can lead to the destruction of a large number of red blood cells, causing a significant release of hemoglobin into the bloodstream. This excessive release of hemoglobin can overwhelm the body's ability to clear it, leading to the accumulation of toxic byproducts such as free hemoglobin and heme. These byproducts can lead to various complications, one of which is the potential for causing shock. Shock is a life-threatening condition characterized by inadequate tissue perfusion and oxygen delivery to vital organs due to a systemic vascular response to the circulating toxins and byproducts of hemolysis. It is a severe consequence of extensive hemolysis and requires immediate medical intervention to stabilize the patient.
Question 4 of 5
A nurse is admitting a toddler to the hospital. The toddler is with both parents and is currently sitting comfortably on a parent's lap. The parents state they will need to leave for a brief period. Which type of nursing diagnosis should the nurse formulate for this child?
Correct Answer: A
Rationale: The appropriate nursing diagnosis for the toddler in this scenario would be "Risk for anxiety." The child is currently comfortable sitting on a parent's lap but may experience increased anxiety when the parents leave for a brief period. Since the parents' departure has not yet occurred and the child's reaction is uncertain, it is more appropriate to identify the potential risk of anxiety rather than stating the child is already experiencing anxiety. This diagnosis focuses on the potential for a negative emotion, providing an opportunity for nursing interventions to prevent or reduce anxiety in the child's upcoming situation.
Question 5 of 5
A patient has end-stage dilated cardiomyopathy. He comes to the emergency department with dyspnea. He says he went to bed and awoke with a feeling of suffocation. He says it was frightening. Which of the ff. responses by the nurse is most appropriate?
Correct Answer: C
Rationale: The most appropriate response by the nurse is option C, "Reclining increases fluid returning to the heart, which builds up fluid in the lungs." In a patient with end-stage dilated cardiomyopathy, reclining position can lead to increased fluid return to the heart due to the failing pump function. This can result in fluid backing up in the lungs, causing symptoms such as dyspnea or feeling of suffocation. By explaining this mechanism to the patient, the nurse can provide valuable information about the condition and the reason for the distressing symptoms experienced by the patient. It also highlights the importance of proper positioning to alleviate symptoms and improve the patient's comfort.