ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 of 5
The nurse understands that which of the ff. best describes the action of enalapril maleate (Vasotec)?
Correct Answer: A
Rationale: Enalapril maleate (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor. The main action of ACE inhibitors like enalapril is to decrease the levels of angiotensin II in the body. Angiotensin II is a potent vasoconstrictor that plays a role in regulating blood pressure, stimulating aldosterone secretion, and promoting sodium and water retention. By inhibiting the conversion of angiotensin I to angiotensin II, enalapril reduces vasoconstriction and aldosterone secretion, leading to vasodilation, decreased blood pressure, and ultimately decreased levels of angiotensin II. This mechanism allows for the dilation of arterioles and veins, reduction in cardiac afterload, and ultimately decreases the workload of the heart.
Question 2 of 5
A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
Correct Answer: C
Rationale: The sudden severe headache and nasal congestion in a client with a spinal cord injury at the level of T3, along with flushed skin, goose bumps, and potentially increased blood pressure due to autonomic dysreflexia. This is a medical emergency that requires immediate intervention from a healthcare provider. Calling the physician ensures prompt assessment and treatment to prevent further complications associated with autonomic dysreflexia, such as hypertensive crisis, seizures, or stroke. It is important to address this situation promptly to prevent any serious consequences for the client's health.
Question 3 of 5
A nurse has been examining the vital signs of the client for the past 2 days. On a particular day, she observe a sudden change in the vital signs of the client. Which of the ff steps should the nurse take immediately?
Correct Answer: A
Rationale: The nurse should immediately inform the physician about the sudden change in the client's vital signs. Sudden changes in vital signs can be indicative of a serious health issue or medical emergency that would require the expertise and intervention of a physician. Prompt communication with the physician is essential to ensure timely assessment, diagnosis, and appropriate treatment for the client. It is crucial to prioritize the client's well-being and safety in such situations, which is why informing the physician is the most appropriate and urgent step to take.
Question 4 of 5
Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson's or Huntington's diseases, or even epilepsy?
Correct Answer: A
Rationale: Emotional counseling and helping with common daily activities are important nursing care interventions for clients with neurologic diseases such as Parkinson's, Huntington's, and epilepsy because these clients often experience depression, anxiety, and difficulty performing basic self-care tasks. These diseases can have a significant impact on the client's mental health, leading to feelings of helplessness and loss of independence. Providing emotional support and assistance with daily activities can help improve the client's overall well-being and quality of life. Additionally, these interventions can also help prevent complications such as complications such as pressure sores, infections, and malnutrition that may arise from the inability to perform self-care tasks independently.
Question 5 of 5
The client is taking phenyton (Dilantin) for seizure control. A sample is drawn to determine the serum drug level, and the nurse reviews the results. Which of the following would indicate a therapeutic serum drug range?
Correct Answer: A
Rationale: The therapeutic serum drug range for phenytoin (Dilantin) is typically considered to be 10 to 20 mcg/ml. However, some sources may cite a broader range of 5 to 20 mcg/ml. Therefore, a serum drug level range of 5 to 10 mcg/ml would fall within the acceptable therapeutic range for phenytoin. Serum levels outside of this range may indicate potential toxicity (above range) or subtherapeutic levels (below range) which could result in inadequate seizure control.