ATI RN
Burns Pediatric Primary Care Test Bank Questions
Question 1 of 5
Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?
Correct Answer:
Rationale: Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys, leading to decreased plasma filtration. As a result, fluid volume excess occurs due to impaired kidney function in regulating the fluid balance. Symptoms may include hypertension, edema, weight gain, and oliguria. Therefore, the most appropriate nursing diagnosis for a child with acute glomerulonephritis would be "Fluid Volume Excess related to decreased plasma filtration". This diagnosis focuses on the pathophysiological process of the condition and helps guide nursing interventions aimed at managing fluid volume overload.
Question 2 of 5
Which nursing diagnosis is most appropriate for a client with Addison's disease?
Correct Answer: C
Rationale: Addison's disease is a condition characterized by adrenal insufficiency, resulting in a deficiency of aldosterone and cortisol. Without aldosterone, the body is unable to regulate fluid and electrolyte balance properly, leading to sodium loss and potassium retention. This imbalance can result in excessive fluid volume, as the kidneys retain water and sodium. Symptoms of excessive fluid volume in Addison's disease can include edema, weight gain, and hypertension. Therefore, the most appropriate nursing diagnosis for a client with Addison's disease would be Excessive Fluid Volume.
Question 3 of 5
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
Correct Answer: B
Rationale: - **Encourage a liberal fluid intake (B):** It is essential to maintain hydration after a lumbar puncture to help prevent or alleviate a headache, which may occur due to a decrease in cerebrospinal fluid (CSF) pressure. Adequate hydration can help reduce the chances of a post-lumbar puncture headache.
Question 4 of 5
If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?
Correct Answer: D
Rationale: Elevated pulmonary vascular pressures can lead to pulmonary hypertension, which causes increased pressure in the right side of the heart. The right ventricle has to work harder to pump blood against the increased resistance in the pulmonary circulation. Over time, this can result in the development of right ventricular hypertrophy as the muscle of the right ventricle thickens in response to the increased workload. This is a compensatory mechanism to try to maintain cardiac output despite the increased pressure in the pulmonary circulation. Left atrial atrophy, left ventricular hypertrophy, and right atrial atrophy are not typically associated with elevated pulmonary vascular pressures.
Question 5 of 5
One of the following is not a feature of attention deficit/hyperactivity disorder (ADHD)
Correct Answer: D
Rationale: Lead intoxication is not a recognized feature of ADHD but rather a separate condition with its own set of symptoms.