ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition?
Correct Answer: A
Rationale: Acute renal failure is characterized by a sudden decrease in kidney function, resulting in the reduced ability to excrete waste products and maintain fluid balance. The primary clinical manifestations typically seen in acute renal failure include oliguria (low urine output) due to decreased kidney function, and hypertension (high blood pressure) as the body retains excess fluid and waste products. These symptoms indicate impaired kidney function and the need for immediate medical intervention to prevent further complications. Hematuria, proteinuria, muscle cramps, bacteriuria, and facial edema are not typically primary clinical manifestations of acute renal failure.
Question 2 of 5
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk?
Correct Answer: C
Rationale: In a child with persistent hypoxia secondary to a cardiac defect, promoting cardiac output is crucial to decreasing the risk of cerebrovascular accidents (strokes). Hypoxia resulting from the cardiac defect can lead to inadequate oxygen supply to the brain, increasing the risk of strokes. By optimizing cardiac output, the body can deliver sufficient oxygen to vital organs, including the brain, reducing the likelihood of cerebrovascular accidents. It is essential to focus on supporting cardiac function to improve overall perfusion and oxygenation levels, ultimately helping to mitigate the risk of strokes in this vulnerable population.
Question 3 of 5
Which occurs in septic shock?
Correct Answer: C
Rationale: In septic shock, vasoconstriction is a common phenomenon. This occurs as part of the body's response to the infection, where blood vessels constrict in an attempt to maintain blood pressure and perfusion to vital organs. The vasoconstriction leads to increased systemic vascular resistance and contributes to the hypotension seen in septic shock. The body's natural response to infection also involves a release of inflammatory mediators, which can cause vasodilation in some areas while concurrent vasoconstriction occurs in others, resulting in uneven blood flow distribution and contributing to organ dysfunction. Therefore, vasoconstriction is a key factor in the pathophysiology of septic shock.
Question 4 of 5
Nocturia
Correct Answer: B
Rationale: Nocturia is the condition of waking up during the night to urinate. The factors associated with it are usually related to Increased nocturnal urine production (2), aging and hormonal changes (3), underlying medical conditions such as diabetes and heart disease (5), and medications that can increase urine production or cause fluid retention (6). Therefore, the correct choices are 2, 3, 5, and 6 which align with B.
Question 5 of 5
While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?
Correct Answer: A
Rationale: The nurse should report the ulcer to the admitting care provider as the first action. An ulcerated area on the penis in an older adult may be indicative of various serious conditions, such as sexually transmitted infections (STIs) or skin breakdown. It is important for the healthcare provider to assess the ulcer, determine the cause, and initiate appropriate treatment. Reporting the finding promptly ensures timely intervention and appropriate management of the patient's condition. This initial action takes priority over teaching about STD prevention or inquiring about the patient's history of syphilis. Cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can potentially worsen the patient's condition.