ATI RN
Burns Pediatric Primary Care Test Bank Questions
Question 1 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 2 of 5
Tic douloureux is a (n) ___ cranial nerve disorder characterized by paroxysms of pain and burning sensations.
Correct Answer: C
Rationale: Tic douloureux, also known as trigeminal neuralgia, is a disorder of the 5th cranial nerve. This condition is characterized by intense, sharp, stabbing, and burning pain that follows the distribution of one or more branches of the trigeminal nerve. The pain occurs in short, sudden attacks or paroxysms, typically triggered by touching specific trigger points or by activities such as eating or speaking. It is important to correctly identify and diagnose the involvement of the 5th cranial nerve in such cases to provide appropriate treatment options for the patient.
Question 3 of 5
To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
Correct Answer: B
Rationale: Checking the bedside for the presence of a hypothermia blanket is crucial for providing safe care for Mrs. Zeno. Hypothermia blankets are used to prevent or treat hypothermia, which is a condition where the body temperature drops below normal levels. Maintaining normothermia (normal body temperature) is important for the overall well-being of patients, especially those who are at risk of developing complications due to temperature fluctuations. Therefore, having a hypothermia blanket readily available at the bedside ensures that the nurse can promptly address any temperature-related issues to optimize Mrs. Zeno's care and safety.
Question 4 of 5
Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
Correct Answer: A
Rationale: When a patient is having a seizure, the primary goal is to keep the patient safe and prevent injury. By easing the patient to the floor, the nurse can prevent potential injury from falling. It is important to ensure there are no objects nearby that can harm the patient during the seizure. Placing something between the patient's jaws or restraining their body movements are not recommended as they can potentially harm the patient or exacerbate the seizure. Once the patient is safely on the floor, the nurse can protect the patient's head, remove any harmful objects, and monitor the seizure until it subsides.
Question 5 of 5
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
Correct Answer: B
Rationale: The 78-year-old male in this scenario is at risk for electrolyte imbalances due to prolonged exposure to high temperatures while taking thiazide diuretics, commonly prescribed for hypertension. The low potassium level (K 3.7 mEq/L) and low sodium level (Na 129 mEq/L) in his lab results are indicative of potential electrolyte disturbances, especially considering his age and medication. These electrolyte imbalances can lead to symptoms like fatigue, muscle weakness, restlessness, and flushed skin, which are signs of hyponatremia and hypokalemia.