ATI RN
Pediatric Nursing Practice Questions Questions
Question 1 of 5
The nurse notes frequent muscle twitching when collecting admission data on a patient admitted for increasing muscle weakness. Which of the ff. terms should the nurse use to document this?
Correct Answer: A
Rationale: Fasciculations are small, involuntary muscle contractions or twitching observed under the skin. In this scenario, the nurse noted frequent muscle twitching in the patient, which aligns with the characteristic manifestation of fasciculations. It is important for the nurse to accurately document this observation as it can provide valuable information to the healthcare team in assessing the patient's condition and determining the underlying cause of the muscle weakness. Chorea refers to irregular, rapid, and jerky movements that are not present in this case. Atrophy indicates muscle wasting, while neuropathy involves damage or dysfunction of nerves, neither of which specifically describes the observed muscle twitching.
Question 2 of 5
Which of the ff. statements does the nurse understand is true concerning air conduction of sound in the ear?
Correct Answer: B
Rationale: Air conduction of sound in the ear involves the transmission of sound waves through the air from the outer ear canal to the middle ear, where they cause the tympanic membrane (eardrum) to vibrate. These vibrations are then transmitted through the ossicles (tiny bones in the middle ear) to the inner ear, where they ultimately stimulate the hair cells in the cochlea to create the auditory nerve impulses. While air conduction is the most common method of sound transmission, it is less efficient than bone conduction. Bone conduction is the transmission of sound vibrations directly to the inner ear through the bones in the skull. This method bypasses the outer and middle ear and is often more efficient in conducting sound, especially at higher frequencies or in individuals with hearing loss related to the outer or middle ear.
Question 3 of 5
A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add?
Correct Answer: A
Rationale: Chronic hyperparathyroidism can lead to excessive bone demineralization due to increased levels of parathyroid hormone. This can weaken the bones and increase the risk for pathologic fractures. Therefore, the most appropriate "related-to" phrase to add to the nursing diagnosis of Risk for injury for a client with chronic hyperparathyroidism would be bone demineralization resulting in pathologic fractures. This accurately reflects the potential risk for injury associated with the client's condition.
Question 4 of 5
Which nursing diagnosis takes highest priority for a client with hyperparathyroidism?
Correct Answer: B
Rationale: Among the listed nursing diagnoses, the highest priority for a client with hyperparathyroidism would be addressing the risk for impaired skin integrity. This is because hyperparathyroidism can lead to increased levels of calcium in the blood, which can result in skin issues such as edema (swelling), skin fragility, and poor wound healing. Addressing this risk is crucial to prevent skin breakdown, infections, and other complications associated with compromised skin integrity. Proper wound care, skin protection measures, and monitoring for any skin changes are essential in managing this priority nursing diagnosis for a client with hyperparathyroidism.
Question 5 of 5
Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:
Correct Answer: A
Rationale: Nurse Maria should immediately cover the wound with a moist sterile dressing to protect the exposed tissue and prevent infection. This action will help maintain the moisture needed for wound healing and reduce the risk of further complications. It is important to cover the exposed area to prevent any external contaminants from entering the wound, while also keeping the area moist to promote healing. It is crucial to seek medical attention promptly to address the situation and ensure proper care for the patient.