ATI RN
ATI Pediatrics Test Bank Questions
Question 1 of 5
Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
Correct Answer: A
Rationale: Age-related changes contribute significantly to the vulnerability of older clients with an immune system disorder. As people age, their immune system undergoes various alterations that can compromise its effectiveness in fighting off infections and diseases. These changes include thymic involution (decrease in thymus size and function), decrease in T-cell production, impaired immune response to infections, and decline in overall immune function. Older individuals are more susceptible to infections due to these age-related changes, which makes it essential for nurses to provide special care tailored to their specific needs. By understanding and considering these age-related immune system changes, nurses can develop appropriate care plans to support the health and well-being of older clients with immune system disorders.
Question 2 of 5
Which of the following would the nurse identify as an abnormal finding?
Correct Answer: C
Rationale: The normal range for platelets in adults is typically between 150,000 to 400,000 platelets per microliter of blood. A platelet count of 115,000/ul would be considered low, a condition known as thrombocytopenia. Thrombocytopenia can result in difficulty with blood clotting and may lead to increased risk of bleeding. Therefore, a platelet count of 115,000/ul would be identified as an abnormal finding by the nurse.
Question 3 of 5
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
Correct Answer: B
Rationale: A reduced hematocrit (Hct) in a client with deep partial-thickness burns can be primarily caused by volume overload with hemodilution. In patients with burns, there is an initial shift of fluid from the intravascular space to the interstitial space, leading to a decreased intravascular volume. In response to this hypovolemia, there is an increased release of antidiuretic hormone (ADH) and aldosterone, resulting in retention of water and sodium. This volume overload leads to hemodilution, where the proportion of red blood cells to plasma decreases, causing a reduction in hematocrit levels. This scenario is a common occurrence in clients with burn injuries and helps explain the reduced hematocrit in this client.
Question 4 of 5
Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
Correct Answer: D
Rationale: Sickle cell crisis is characterized by intense pain due to the vaso-occlusive properties of sickled red blood cells leading to tissue ischemia. Therefore, pain is the primary nursing diagnosis that the nurse should expect to see in the plan of care for a client experiencing a sickle cell crisis. Managing and alleviating the pain is a priority in the care of these clients to improve quality of life and prevent complications. Other nursing diagnoses such as imbalanced nutrition, disturbed sleep pattern, and impaired skin integrity may not be directly related to the acute crisis and would not be the priority focus of care in this situation.
Question 5 of 5
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Correct Answer: C
Rationale: The nursing diagnosis that takes the highest priority for a client in a late stage of AIDS with signs of AIDS-related dementia is Ineffective cerebral tissue perfusion. This diagnosis is prioritized because AIDS-related dementia is associated with changes in brain function due to HIV affecting the brain tissues. Ensuring adequate cerebral perfusion is crucial to maintaining brain function and preventing further deterioration. Monitoring and addressing any factors that could affect cerebral perfusion, such as blood pressure, oxygenation, and circulation, are essential in managing this condition. Other nursing diagnoses are also important, but addressing ineffective cerebral tissue perfusion should be the highest priority in this situation to prevent further complications related to neurological function.