ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
Mr. Kawasaki, a 23-year old industrial worker, was burned severely in an industrial accident. He has second degree burns on his right leg and arm, and on his left leg. He has third degree burns on his left arm. The triage nurse, using the rule of nines, estimates the extent of burn as:
Correct Answer: C
Rationale: The rule of nines is a method used to quickly estimate the extent of burns on a patient's body. According to the rule of nines, each area of the body is assigned a percentage that represents its proportional size compared to the total body surface area. In adults, the body is divided into areas of 9% or multiples of 9%.
Question 2 of 5
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
Correct Answer: D
Rationale: Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone, leading to a slowing down of the body's metabolic processes. One of the hallmark symptoms of hypothyroidism is extreme fatigue or tiredness. This can be due to the overall decrease in metabolic rate affecting energy levels and causing a feeling of exhaustion. Other common symptoms of hypothyroidism include weight gain, cold intolerance, constipation, dry skin, and depression. Tachycardia (fast heart rate), hyperthermia (elevated body temperature), and weight loss are not typically associated with hypothyroidism, but rather with conditions such as hyperthyroidism where there is an excess of thyroid hormone production.
Question 3 of 5
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
Correct Answer: B
Rationale: The rationale for administering the oil retention enema first in this case is to help soften the fecal mass and lubricate the walls of the rectum and colon. This will make it easier for the impacted stool to be passed, reducing the risk of injury or discomfort during the procedure. The oil enema acts as a lubricant, making it easier for the hardened fecal mass to be expelled from the body without causing damage to the intestinal walls. Additionally, the oil enema helps to soften the fecal mass, further aiding in its removal.
Question 4 of 5
. A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?
Correct Answer: C
Rationale: Addison's disease, also known as adrenocortical insufficiency, is characterized by a deficiency in adrenal cortex hormones, particularly glucocorticoids and mineralocorticoids. One of the characteristic findings in Addison's disease is hyperkalemia, which is an elevated serum potassium level. This is due to the lack of aldosterone production by the adrenal glands, leading to decreased potassium excretion by the kidneys. Therefore, a serum potassium level of 5.8 mEq/L would best support a diagnosis of Addison's disease among the given laboratory test results.
Question 5 of 5
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.