ATI LPN
Immune System Questions Questions
Question 1 of 5
When completing the child’s admission assessment, which of the following components of the abdominal assessment should the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Palpation. During a child's admission assessment, the nurse should avoid palpation of the abdomen because it can potentially cause discomfort or pain to the child, especially if there is an underlying abdominal issue. Instead, the nurse should prioritize other components such as inspection, auscultation, and percussion. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation helps in listening for bowel sounds, which can provide valuable information about gastrointestinal function. Percussion can assist in identifying areas of tenderness or abnormal fluid accumulation. Palpation should be performed cautiously and only if necessary, after obtaining consent and ensuring the child is comfortable.
Question 2 of 5
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A: Splints. Splints help immobilize joints, reducing pain and preventing further damage in clients with joint pain due to DIC. Cool compresses (B) may provide temporary relief but won't address the underlying issue. Heat (C) can worsen inflammation in joints. Ice (D) is contraindicated in DIC as it can exacerbate clotting issues.
Question 3 of 5
A child is diagnosed with thrombocytopenia secondary to chemotherapy treatments. Which action by the nurse is not appropriate?
Correct Answer: A
Rationale: The correct answer is A: Administer intramuscular injections (IM). In a child with thrombocytopenia, the platelet count is low, leading to an increased risk of bleeding. Administering IM injections can cause bleeding at the injection site due to the potential trauma to blood vessels. Performing oral hygiene (B), monitoring intake and output (C), and using palpation as a component of assessment (D) are appropriate actions that do not pose a significant risk of bleeding in a child with thrombocytopenia. It is crucial to prioritize interventions that minimize the risk of bleeding complications in this scenario.
Question 4 of 5
Which of the following would be an appropriate nursing diagnosis for a child who is receiving chemotherapy?
Correct Answer: D
Rationale: The correct answer is D: Impaired oral mucous membrane. This is an appropriate nursing diagnosis for a child receiving chemotherapy because chemotherapy often causes mucositis, leading to pain, difficulty eating, and an increased risk of infection in the oral cavity. Nurses need to assess and monitor oral mucous membranes closely in these patients. Incorrect choices: A: Ineffective breathing pattern - Not directly related to chemotherapy in this scenario. B: Constipation - Not typically a common issue specifically related to chemotherapy. C: Impaired skin integrity - Not directly related to the side effects of chemotherapy on oral mucous membranes.
Question 5 of 5
A child who has nephrotic syndrome is admitted to the pediatric unit. Which of the following should the nurse expect to find? (Select one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A: Decreased urine specific gravity. In nephrotic syndrome, there is increased protein loss in the urine, leading to proteinuria and hypoalbuminemia. This results in a decrease in colloid osmotic pressure, causing fluid to leak into the interstitial spaces, leading to edema. Hyperlipidemia occurs due to the liver's response to low serum albumin levels. However, urine specific gravity is typically normal or even increased due to the concentrated urine caused by the loss of proteins and other solutes. Therefore, the nurse should not expect to find decreased urine specific gravity in a child with nephrotic syndrome.