ATI RN
Essential of Pediatric Nursing Test Bank Questions
Question 1 of 5
The client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result?
Correct Answer: A
Rationale: A phenytoin blood level of 35 mcg/ml is considered to be above the therapeutic range (usually 10-20 mcg/ml for phenytoin). At this elevated level, the client is at risk for phenytoin toxicity. Symptoms of phenytoin toxicity include nystagmus (rapid, involuntary eye movements), as well as other symptoms such as confusion, slurred speech, ataxia, and tremors. Tachycardia is not typically associated with phenytoin toxicity. Therefore, the expected symptom in this case would be nystagmus.
Question 2 of 5
The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?
Correct Answer: A
Rationale: In a normal healthy individual, the rate of the radial pulse (peripheral pulse) and the heart rate (apical pulse) should be the same. This is because each heartbeat should result in a corresponding pulse felt at the radial artery in the wrist. The pulse is generated by the heart's contraction and the subsequent ejection of blood into the arteries, causing a wave of pressure that can be felt as the pulse. Therefore, in a healthy individual, the radial pulse rate should match the heart rate. If there is a significant difference between the two rates, it may indicate a cardiovascular abnormality or other underlying health condition that warrants further investigation.
Question 3 of 5
An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?
Correct Answer: B
Rationale: The priority nursing action in this situation is to refer the adolescent for prenatal care. Prenatal care is crucial for monitoring the health of both the mother and the baby throughout the pregnancy. This includes assessing for any potential complications, providing appropriate interventions, and ensuring proper support for a healthy pregnancy. It is important for the adolescent to receive medical care as soon as possible to optimize the outcomes for both her and her baby. While notifying her parents, explaining the importance of not smoking, and discussing dietary needs are also important aspects of care, ensuring timely access to prenatal care is the most critical priority in this scenario.
Question 4 of 5
Which of the following conditions is suspected?
Correct Answer: C
Rationale: Leukemia is a type of cancer that affects the blood and bone marrow, leading to an overproduction of abnormal white blood cells. The symptoms of leukemia can include fatigue, weakness, weight loss, frequent infections, fever, bruising or bleeding easily, and bone pain. Given the vague presenting symptoms and the potential involvement of multiple bodily systems, leukemia is a condition that should be suspected and investigated further. Anemia, rheumatic arthritis, and systematic lupus erythematosus can also present with some similar symptoms, but for the given scenario, leukemia is the most probable condition to suspect.
Question 5 of 5
A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?
Correct Answer: C
Rationale: Breaking the task down into simple steps is the best response by the nurse to help the patient get the task done. By breaking the task into smaller, more manageable steps, the patient can focus on completing each step successfully, leading to a sense of accomplishment and reducing frustration. This approach promotes a positive and empowering experience for the patient, ultimately aiding in their recovery and rehabilitation process.