ATI RN
Pediatric Nursing Practice Questions Questions
Question 1 of 5
When performing a neurological examination on Mr. RR, which of the following would not be considered an important or useful part of the examination?
Correct Answer: D
Rationale: When performing a neurological examination on Mr. RR, pupil size due to neurologic medications would not typically be considered an important or useful part of the examination. While assessing pupil size and reactivity can provide valuable information about brain function and potential neurological issues, the focus of the initial examination would generally be on assessing eye movements, reflexes, and signs of nuchal rigidity. Pupil size related to medications would be more relevant in a medication review or history-taking rather than in the initial neurological examination.
Question 2 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 3 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 4 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.
Question 5 of 5
Mrs. Tan was prescribed with nitroglycerin. Nurse Amalia teaches her about the common side effect of the drug which includes:
Correct Answer: D
Rationale: Nitroglycerin is commonly known to cause a side effect of throbbing headache. Nitroglycerin works by dilating blood vessels to improve blood flow to the heart, which can sometimes lead to headaches due to the sudden increase in blood flow. This headache is often described as throbbing and can be quite bothersome. It is important for patients taking nitroglycerin to be aware of this common side effect and to consult their healthcare provider if the headaches become severe or persistent.