ATI LPN
Immune System Practice Questions Questions
Question 1 of 5
The nurse is caring for a child with disseminated intravascular coagulation (DIC). Which nursing intervention is a priority for this child?
Correct Answer: B
Rationale: The correct answer is B: Maintenance of skin integrity. For a child with DIC, skin integrity is a priority due to the risk of bleeding and clotting. Skin breakdown can lead to infection and further complications. Monitoring fluid restriction (choice C) may be important, but skin integrity takes precedence. Frequent ambulation (choice A) may be beneficial but not as crucial as maintaining skin integrity. Preparation for x-ray procedures (choice D) is not a priority compared to preventing skin breakdown in a child with DIC.
Question 2 of 5
The child is admitted to the hospital after being diagnosed with retinoblastoma. Which assessment finding does the nurse anticipate for this child?
Correct Answer: C
Rationale: The correct answer is C: A white pupil. Retinoblastoma is a malignant tumor of the retina that can present as a white pupil in flash photography, known as leukocoria. This is due to the tumor blocking the normal red reflex from the retina. A red reflex (choice A) is a normal finding and not expected in retinoblastoma. Yellow sclera (choice B) and blue-tinged sclera (choice D) are not typically associated with retinoblastoma.
Question 3 of 5
A nurse enters the room of a teenager after the physician has obtained informed consent for a voiding cystourethrogram. The teenager asks the nurse to explain the procedure again. The nurse tells the client that the client is asked to void after:
Correct Answer: C
Rationale: The correct answer is C: Injection of contrast dye into the bladder via a catheter. In a voiding cystourethrogram, contrast dye is indeed injected into the bladder via a catheter to visualize the urinary tract during voiding. This allows for the assessment of bladder and urethra function. Choices A and D are incorrect because radioisotopes are not typically used in this procedure. Choice B is incorrect as contrast dye is not injected into the bloodstream but rather directly into the bladder. Therefore, the correct answer is C as it accurately describes the procedure for a voiding cystourethrogram.
Question 4 of 5
A nurse is assisting with the admission of a toddler who has nephrotic syndrome. Which of the following objective data should the nurse anticipate collecting from the child?
Correct Answer: A
Rationale: The correct answer is A: Elevated blood pressure. In nephrotic syndrome, there is a loss of protein in the urine, leading to hypoalbuminemia and fluid retention, which can result in elevated blood pressure. This is due to the body's attempt to maintain fluid balance. Option B is incorrect because in nephrotic syndrome, serum cholesterol and fat levels are typically elevated, not lower than normal. Option C is incorrect as 3+ to 4+ protein in the urine is indicative of proteinuria, a common finding in nephrotic syndrome. Option D is incorrect as thin limbs with loose skin are not typically associated with nephrotic syndrome.
Question 5 of 5
The nurse admitting and assessing a teenage boy with suspected testicular torsion (twisted testicle) will most likely find which of the following manifestations in addition to possible nausea and vomiting and acute testicular pain?
Correct Answer: B
Rationale: The correct answer is B: Cremasteric reflex depressed or absent. Testicular torsion causes twisting of the spermatic cord, cutting off blood supply to the testicle, leading to severe pain, nausea, and vomiting. The cremasteric reflex, which causes the testicle to elevate when the inner thigh is stroked, is typically absent in cases of testicular torsion due to the severe pain and ischemia. Choices A, C, and D are incorrect as relief of pain with elevation of the testicle, pain or discomfort upon urination, and presence of white blood cells and bacteria in the urine are not typical manifestations of testicular torsion.