ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 of 5
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
Correct Answer: C
Rationale: When treating hypoglycemia, it is important to provide a quick source of sugar to raise blood glucose levels rapidly. Consuming 10 to 15 grams of a simple carbohydrate is appropriate for treating mild to moderate hypoglycemia. Examples of foods that contain approximately 10 to 15 grams of simple carbohydrates include four glucose tabs, 4 ounces of fruit juice, 5 to 6 pieces of hard candy, or 1 tablespoon of honey. It is also recommended to recheck blood glucose levels after 15 minutes and have a snack or meal to prevent glucose levels from dropping again.
Question 2 of 5
Autoimmunity is defined as a phenomenon involving which of the following?
Correct Answer: D
Rationale: Autoimmunity is a phenomenon in which the immune system mistakenly targets and attacks the body's own cells, tissues, and organs. This occurs due to a breakdown in the immune system's ability to differentiate "self" from "nonself." In a healthy immune system, immune cells recognize and destroy foreign invaders while avoiding attacking the body's own cells. When this self-tolerance is lost, autoimmune diseases can develop, leading to inflammation, tissue damage, and various health problems. Therefore, autoimmunity is defined by the immune system's inability to distinguish between self and nonself.
Question 3 of 5
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
Correct Answer: C
Rationale: A non-mobile mass with irregular edges is a strong indicator of a cancerous lump in the breast. Cancerous lumps often feel fixed or attached to the surrounding tissue and may have irregular shapes rather than smooth, round contours. The lack of mobility and irregular edges increase suspicion for malignancy and warrant further investigation, such as imaging studies and biopsies. It is important for this patient to follow up with a healthcare provider promptly for further evaluation and appropriate management.
Question 4 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 5 of 5
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
Correct Answer: E
Rationale: Clients with immune system disorders may receive treatments such as immunoglobulin therapy or biologic agents through infusions. It is essential for the nurse to monitor the client for infusion reactions, which can include symptoms such as fever, chills, nausea, and allergic reactions. Early recognition of infusion reactions is crucial for prompt intervention to prevent complications and ensure the client's safety. By closely monitoring the client during and after the infusion, the nurse can detect and address any adverse reactions promptly.