ATI RN
Pediatric HESI Test Bank Questions
Question 1 of 5
Which nursing interventions can help prevent falls in a patient with Parkinson's disease? Choose all answers that are correct. i.Keep the patient's call light within reach ii.Apply a soft vest restraint when the patient is in bed iii.Avoid use of throw rugs iv.Maintain the patient's bed in a low position v.Encourage the patient to be independent for as long as possible vi.Provide a cane or walker for ambulation
Correct Answer: A
Rationale: The correct answer is A, which includes the following nursing interventions to help prevent falls in a patient with Parkinson's disease: keeping the patient's call light within reach and maintaining the bed in a low position. Keeping the call light within reach ensures that the patient can easily call for assistance when needed, reducing the risk of falls when trying to reach for help. Maintaining the bed in a low position minimizes the risk of injury if the patient were to fall out of bed. The incorrect options can be explained as follows: - Option B includes using a soft vest restraint, which is not recommended as it can increase the risk of injury and agitation in patients with Parkinson's disease. - Option C suggests avoiding throw rugs, which is a good practice, but it does not directly address fall prevention strategies specific to patients with Parkinson's disease. - Option D includes providing a cane or walker for ambulation, which is generally a good intervention but may not be suitable for all patients with Parkinson's disease who have specific gait and balance issues. In an educational context, it is crucial for nursing students to understand the unique challenges faced by patients with Parkinson's disease, such as impaired balance and coordination, which increase their risk of falls. Implementing tailored interventions, like those in option A, can help students provide safe and effective care to these patients, promoting positive health outcomes.
Question 2 of 5
A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?
Correct Answer: D
Rationale: Guillain-Barre Syndrome (GBS) is an autoimmune disorder where the body's immune system mistakenly attacks the peripheral nerves. This leads to inflammation that damages the nerves and interrupts their ability to send signals to the brain. In the case of the 32-year-old male patient with weak legs, the autoimmune reaction is most likely responsible for causing muscle weakness and difficulty walking. GBS typically presents with ascending muscle weakness starting in the legs and progressing upwards. It is essential to recognize this condition promptly as it can lead to severe complications such as respiratory failure. Treatment often involves supportive care and interventions to manage the autoimmune response.
Question 3 of 5
Which of the ff conditions are more likely to develop in a client who is relatively immobile for the rest of his or her life? Choose all that apply
Correct Answer: A
Rationale: In a client who is relatively immobile for the rest of their life, the correct answer is A) Bladder infection. Immobility can lead to urinary stasis, which creates a conducive environment for bacterial growth in the bladder, increasing the risk of bladder infections. Option B) Constipation is also a common issue in immobile clients due to decreased abdominal muscle tone and peristalsis. However, it is not directly related to immobility as bladder infections are. Option C) Calculus formation is less likely to develop due to immobility alone. It is more related to factors like diet and hydration. Option D) Bladder inflammation is a general term and not as specific as a bladder infection which is more likely in immobile clients. Educationally, understanding the impact of immobility on various body systems is crucial for healthcare providers, especially when caring for patients with limited mobility. This knowledge helps in preventing and managing potential complications effectively, improving overall patient outcomes.
Question 4 of 5
The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
Correct Answer: B
Rationale: Acetaminophen toxicity can lead to hepatic injury, resulting in elevated liver enzymes, including bilirubin levels. Direct bilirubin is a specific marker for liver function and is typically elevated in cases of acetaminophen overdose or toxicity. Therefore, a direct bilirubin level of 2 mg/dl would indicate toxicity associated with acetaminophen use. Monitoring liver function tests, including bilirubin levels, is crucial when using acetaminophen long-term to prevent toxicity and liver damage.
Question 5 of 5
The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply
Correct Answer: C
Rationale: Normal intraocular pressure (IOP) typically ranges between 10 and 21 mm Hg. For this reason, the tonometer measurements of 11 mm Hg and 20 mm Hg fall within the normal range. Therefore, clients with these IOP values (Option C and E) have normal intraocular pressure. The other options (A, B, and D) are outside the normal range for IOP and are therefore considered elevated.