ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
The initial neurological symptom of Guilain-Barre Syndrome is:
Correct Answer: B
Rationale: The initial neurological symptom of Guillain-Barre Syndrome (GBS) is typically paresthesia, which is a tingling or numbness sensation in the legs. GBS is an autoimmune disorder that affects the peripheral nervous system, leading to muscle weakness and paralysis. As the condition progresses, symptoms may worsen and may include absent tendon reflexes, weakness in the arms and legs, and difficulty breathing. However, paresthesia is often one of the earliest and most common symptoms of GBS.
Question 2 of 5
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
Correct Answer: B
Rationale: Decorticate posturing is characterized by flexion of elbows, wrists, and fingers; extension of elbows and knees; plantar flexion of the feet. This type of posturing typically indicates severe damage to the cerebral hemispheres or impairment of the corticospinal tract. When a client with increased intracranial pressure (ICP) displays decorticate posturing, it suggests significant brain injury and dysfunction. This abnormal posturing is a classic sign that requires immediate medical attention and intervention.
Question 3 of 5
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
Correct Answer: A
Rationale: When a patient is placed on seizure precautions, obtaining oral temperature would be contraindicated. This is because sticking a thermometer in the mouth may pose a risk during a seizure episode, as the patient might bite down on it and cause injury. It is important to prioritize safety measures to minimize the risk of harm to the patient. Other methods of monitoring temperature, such as using a tympanic thermometer or a forehead thermometer, would be more appropriate in this situation.
Question 4 of 5
A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?
Correct Answer: A
Rationale: The client is experiencing muscle weakness and numbness in his legs, which are symptoms commonly associated with hyperkalemia (high potassium levels). The potassium level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can lead to muscle weakness, numbness, and potentially more severe complications like cardiac arrhythmias.
Question 5 of 5
Clinical manifestations of Huntington's disease include:
Correct Answer: D
Rationale: Huntington's disease is a progressive neurological disorder that affects movement, cognition, and behavior. The three main clinical manifestations of Huntington's disease are abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is characterized by involuntary jerky movements that are often random and unpredictable. Intellectual decline includes difficulties with cognitive functions such as planning, organizing, and remembering. Emotional disturbances may manifest as irritability, depression, anxiety, or mood swings. Overall, individuals with Huntington's disease experience a wide range of symptoms that impact both their physical and mental well-being.