ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition that involves widespread activation of coagulation leading to microthrombi formation in blood vessels throughout the body. This process can lead to consumption of clotting factors and platelets, causing both bleeding and thrombosis. In the context of DIC, there is a risk for altered tissue perfusion due to the combination of bleeding and microthrombi formation, which can impair blood flow to vital organs and tissues. This condition can ultimately result in organ dysfunction and failure, making it a significant concern in the care of a client with DIC. Therefore, the correct nursing diagnosis for a client with DIC is alteration in tissue perfusion related to bleeding and diminished blood flow.
Question 2 of 5
a woman who is pregnant is undergoing an amniocentesis. during the test, elevated levels of AFP are found. this indicate to which of the following conditions :
Correct Answer: B
Rationale: Elevated levels of AFP (alpha-fetoprotein) in the amniotic fluid during an amniocentesis often indicate neural tube defects, such as spina bifida. Spina bifida is a condition where the spinal cord does not develop properly, leading to a range of possible issues depending on the severity of the defect. In this case, the elevated AFP levels point towards a higher likelihood of spina bifida rather than other conditions like CP (cerebral palsy), Down syndrome, or hydrocephalus.
Question 3 of 5
For most children with enuresis, the only test recommended is
Correct Answer: C
Rationale: Urinalysis is the standard initial test for evaluating enuresis to rule out urinary tract infections or other conditions.
Question 4 of 5
A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
Correct Answer: D
Rationale: Class V findings on a Pap test indicate the presence of severely abnormal cells, suggesting a high likelihood of precancerous or cancerous changes. Therefore, it calls for a biopsy as soon as possible to further investigate and determine the appropriate course of action. Immediate follow-up and intervention are crucial in cases of Class V Pap test results to address any potential serious health concerns.
Question 5 of 5
The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
Correct Answer: D
Rationale: A vesicle is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid. Serous fluid is a clear, watery fluid that can accumulate within the vesicle. Vesicles are commonly seen in conditions such as herpes simplex virus infections (cold sores) and contact dermatitis. It is important for nursing students to understand the characteristics of different skin lesions to accurately assess and provide appropriate care for patients.