ATI RN
Burns Pediatric Primary Care Test Bank Questions
Question 1 of 5
Which of the ff are the symptoms of basilar skull fracture? Choose all that apply
Correct Answer: A
Rationale: Raccoon eyes and Battle's sign are classic signs of basilar skull fracture. Raccoon eyes refer to the presence of bruising or discoloration around the eyes, resembling the appearance of a raccoon. This occurs due to blood collecting in the soft tissues around the eyes. Battle's sign is bruising behind the ear, which can also indicate a basilar skull fracture.
Question 2 of 5
Amy, age 6 years, needs to be hospitalized again because of a chronic illness. The clinic nurse overhears her school-age siblings tell her, "We are sick of Mom always sitting with you in the hospital and playing with you. It isn't fair that you get everything and we have to stay with the neighbors." Which is the nurse's best assessment of this situation?
Correct Answer: B
Rationale: Jealousy and resentment are common reactions among siblings when one child requires more attention due to illness or hospitalization. It is natural for siblings to feel left out, overlooked, or envious of the extra attention the sick child is receiving. These feelings do not necessarily indicate immaturity or being spoiled but rather a normal emotional response to a challenging family situation. It is important for healthcare providers to recognize and address these feelings to support the entire family in coping with the chronic illness of one of their members.
Question 3 of 5
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
Correct Answer: D
Rationale: Assessing the client's ability to produce antibodies is a crucial factor in determining immune system function. Antibodies are proteins produced by the immune system to help fight off infections and other harmful substances. In a male client suspected of an immune system disorder, understanding his ability to produce antibodies can provide valuable insights into the functionality of his immune system. This assessment can help healthcare providers identify potential deficiencies or abnormalities in the immune response, leading to appropriate diagnosis and treatment strategies.
Question 4 of 5
For a client diagnosed with idiopathic thrombocytopenic purpura (ITP), which nursing intervention is appropriate?
Correct Answer: B
Rationale: The appropriate nursing intervention for a client diagnosed with idiopathic thrombocytopenic purpura (ITP) is administering platelets, as ordered, to maintain an adequate platelet count. ITP is a condition characterized by a decrease in platelet count, which can lead to thrombocytopenia and an increased risk of bleeding. Administering platelets can help prevent excessive bleeding and maintain hemostasis in these patients. Platelet transfusions may be required in severe cases to raise the platelet count to a safe level and prevent bleeding complications. It is crucial for nurses to monitor the platelet count regularly and administer platelets as prescribed to manage ITP effectively.
Question 5 of 5
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
Correct Answer: C
Rationale: Providing for frequent rest periods is the most appropriate intervention for a client newly diagnosed with radiation-induced thrombocytopenia. Thrombocytopenia is characterized by a decreased number of platelets, which are essential for blood clotting. Clients with thrombocytopenia are at an increased risk for bleeding and bruising. Therefore, it is important to prevent activities that may lead to injury or bleeding. Providing frequent rest periods allows the client to conserve energy and minimize the risk of trauma that could lead to bleeding complications. This intervention helps manage the symptoms associated with thrombocytopenia and promotes the client's safety and well-being.