ATI RN
NCLEX RN Pediatric Questions Questions
Question 1 of 5
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
Correct Answer: C
Rationale: Elevating the head of the bed is an important intervention to help prevent complications in patients with impaired respiratory function. By elevating the head of the bed, gravity assists in improving lung expansion and ventilation, making breathing easier for the patient. This position promotes better airflow and can help reduce the risk of respiratory complications such as aspiration. It is a non-invasive and simple intervention that can be easily implemented in a home care setting to support the patient's respiratory function and overall well-being. Antibiotics, bedrest, and scheduled suctioning are not directly related to improving respiratory function in this context.
Question 2 of 5
Which of the following would indicate that the patient has a normal corneal light reflex?
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
Question 3 of 5
Which of the following would the nurse teach the patient is the most common site for ear infections?
Correct Answer: B
Rationale: The most common site for ear infections is the middle ear. This area is prone to infections, especially in children, due to the Eustachian tube being shorter and more horizontal compared to adults. The middle ear is connected to the upper respiratory tract, allowing bacteria or viruses to easily travel and cause infections in this area. Symptoms of a middle ear infection include ear pain, fluid buildup, and possible hearing loss. Treatment may involve antibiotics and pain relief medications, and in some cases, surgical intervention may be necessary to drain the fluid.
Question 4 of 5
A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, "This must be a mistake. No one in my family has ever had diabetes." Based on this statement, the nurse suspects the client is using which coping mechanism?
Correct Answer: A
Rationale: The client's response of stating that diabetes cannot be possible because it is not prevalent in the family indicates that the client is using the coping mechanism of denial. Denial is a common defense mechanism where individuals refuse to accept reality or facts that are too uncomfortable for them to acknowledge. In this situation, the client is denying the diagnosis of diabetes as a way to cope with the distressing news, hoping that it may not be true because it has not affected their family members in the past. Recognizing this coping mechanism is important for the nurse to provide support and education to help the client come to terms with the diagnosis and start managing the condition effectively.
Question 5 of 5
A 27-year old adult is admitted for treatment of Crohn's disease. Which information is most significant when the nurse assesses nutritional health?
Correct Answer: A
Rationale: Anthropometric measurements, such as height, weight, body mass index (BMI), and waist circumference, are essential in assessing the nutritional health of a patient with Crohn's disease. These measurements provide objective data about the patient's nutritional status, body composition, and risk for malnutrition. Monitoring changes in these measurements over time can help identify nutritional deficiencies, weight loss, or malnutrition in patients with Crohn's disease. Dry skin, bleeding gums, and facial rubor can be symptoms of other health conditions, but anthropometric measurements directly assess the nutritional health of the patient.