ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 of 5
The primary underlying disorder of pulmonary edema is:
Correct Answer: A
Rationale: Pulmonary edema is a condition where fluid accumulates in the air sacs of the lungs, leading to difficulty breathing. The primary underlying disorder of pulmonary edema is often decreased left ventricular pumping. When the left ventricle of the heart fails to effectively pump blood to the rest of the body, it can lead to a backlog of blood in the pulmonary circulation. This increase in pressure in the pulmonary circulation can cause fluid to leak out of the capillaries and into the alveoli of the lungs, resulting in pulmonary edema. Therefore, decreased left ventricular pumping is a key factor in the development of pulmonary edema.
Question 2 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 3 of 5
Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
Correct Answer: A
Rationale: A decreasing level of consciousness is a symptom often associated with increased intracranial pressure (ICP). When the pressure inside the skull rises, it can compress and damage the brain, leading to a deterioration in consciousness. Common causes of increased ICP include traumatic brain injury, brain tumors, and infections. As ICP continues to rise, it can result in serious consequences such as brain herniation, which can be life-threatening if not promptly managed. Therefore, a decreasing level of consciousness should raise concerns about increased ICP and warrant immediate medical evaluation and intervention.
Question 4 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 5 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.