ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 of 5
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
Correct Answer: B
Rationale: Dilated pupils can cause increased sensitivity to light, leading to discomfort or visual disturbances. Wearing sunglasses can help protect the eyes from bright light and reduce potential discomfort for the patient. This safety instruction is important to promote the patient's comfort and prevent any potential harm due to light sensitivity.
Question 2 of 5
Which of the following is the most critical intervention needed for a client with myxedema coma?
Correct Answer: A
Rationale: Myxedema coma is a severe form of hypothyroidism that can lead to life-threatening complications, including decreased level of consciousness, hypothermia, respiratory depression, and cardiovascular collapse. Rapid administration of thyroid hormone replacement therapy, such as levothyroxine, is crucial in the management of myxedema coma to reverse the underlying hypothyroid state and improve clinical outcomes. Therefore, administering an oral dose of levothyroxine is the most critical intervention needed for a client with myxedema coma. While warming the client with a warming blanket, measuring intake and output, and maintaining a patent airway are important aspects of care, they are not as directly related to the reversal of the underlying hypothyroid state in myxedema coma as administering levothyroxine.
Question 3 of 5
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
Correct Answer: C
Rationale: Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease, such as cirrhosis, where the liver's ability to metabolize ammonia is impaired. As a result, there is an increase in serum ammonia levels, leading to alterations in brain function and neurotransmission. Symptoms such as confusion, restlessness, and asterixis (flapping tremor) are characteristic of hepatic encephalopathy caused by increased ammonia levels affecting the brain. Therefore, altered thought processes in Mrs. Silang are primarily related to the increased serum ammonia levels rather than other factors like massive ascites formation, fluid volume excess, or altered clotting mechanism.
Question 4 of 5
Mr. Umali, 52-year-old male is being evaluated for acute ulcerative colitis. im preparing Mr. Umali for a barium enema, the nurse can expect that he will be:
Correct Answer: A
Rationale: In preparing a 52-year-old male patient like Mr. Umali for a barium enema to evaluate acute ulcerative colitis, the nurse can expect that he will be contraindicated with cathartics. Cathartics, which are substances that induce bowel movements, are generally contraindicated in patients being evaluated for acute colitis as they can exacerbate the condition and cause additional discomfort. In contrast, using oil retention enemas or radiopaque tablets may not be suitable for a patient with acute ulcerative colitis. Positioning in a high Fowler's position following the procedure is not related to the preparation for a barium enema in this case.
Question 5 of 5
One of the side effects of INH administration is peripheral neuropathy. To prevent this effect, Nurse Carlos teaches Andrew to:
Correct Answer: C
Rationale: Pyridoxine, also known as vitamin B6, is necessary for the prevention of INH-induced peripheral neuropathy. INH can lead to a deficiency of vitamin B6 in the body, which in turn can cause nerve damage and peripheral neuropathy. By supplementing the diet with pyridoxine, the risk of developing peripheral neuropathy as a side effect of INH administration can be minimized. It is an important preventive measure recommended for those undergoing treatment with INH to ensure the proper functioning of the nervous system and prevent nerve damage.