ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 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 2 of 5
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
Correct Answer: C
Rationale: The signs and symptoms described - nausea, elevated temperature, tachycardia, and extreme restlessness - are indicative of a thyroid crisis, also known as thyroid storm. A thyroid storm is a life-threatening condition that can occur after thyroid surgery such as a subtotal thyroidectomy. It is characterized by an exaggerated state of hyperthyroidism, leading to a surge of thyroid hormones in the bloodstream. This can result in severe symptoms such as high fever, tachycardia, nausea, agitation, and even confusion or delirium.
Question 3 of 5
You have the results of PCR tests for Mycoplasma pneumoniae; the number of positive tests is 83 collected from a 100 truly-infected persons. The sensitivity of this test is
Correct Answer: D
Rationale: Sensitivity = (True positives / Truly infected) * 100 = (83 / 100) * 100 = 83%.
Question 4 of 5
A nurse notes that a 12-hour-old newborn has not had the first meconium stool. The nurse documents this finding and continues to monitor the newborn because, in term newborns, the first meconium stool occurs within how many hours of birth?
Correct Answer: A
Rationale: In term newborns, the first meconium stool typically occurs within the first 6 to 8 hours after birth. Meconium is the baby's first stool, and its presence signifies that the baby's gastrointestinal system is functioning properly. If a newborn has not passed meconium within this timeframe, it may indicate an issue such as bowel obstruction that requires further evaluation and intervention. Therefore, the nurse should document and monitor the situation closely to ensure the newborn's health and well-being.
Question 5 of 5
Which of the following would the nurse use to document a finding that the patient's ear is draining?
Correct Answer: A
Rationale: Otorrhea is the medical term used to describe drainage from the ear. It is a finding that indicates the ear is draining fluid, which can be a sign of infection or other underlying issues. Otalgia refers to ear pain, ototoxic refers to substances that can damage the ear, and tinnitus refers to ringing in the ears. Therefore, otorrhea is the most appropriate term to document the finding of a draining ear.