ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
Correct Answer: B
Rationale: Widening pulse pressure is indicative of increasing intracranial pressure (ICP) and must be reported immediately. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. An increasing pulse pressure can suggest a rise in ICP due to factors like cerebral edema or hemorrhage. This change indicates increased pressure exerted on blood vessels within the brain, potentially leading to serious consequences like brain herniation. Thus, recognizing and promptly reporting a widening pulse pressure is crucial to prevent further complications and enable appropriate interventions for the patient.
Question 2 of 5
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?
Correct Answer: A
Rationale: Monitoring intake and output is essential in assessing for electrolyte imbalances and dehydration in a client with a neurologic deficit. Unlike options B, C, and D, measuring intake and output provides direct information on the client's fluid balance and kidney function. Electrolyte imbalances can lead to neurological complications and alterations in mental status, making it crucial to keep track of the amounts of fluids ingested and excreted by the client. Additionally, dehydration can exacerbate neurological deficits, so monitoring intake and output can help prevent this complication.
Question 4 of 5
The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?
Correct Answer: C
Rationale: Phenytoin (Dilantin) is known to be incompatible with dextrose solutions (such as dextrose 5% or dextrose 5% and half-normal saline). Therefore, the nurse would plan to use normal saline solution to dilute phenytoin in order to ensure medication effectiveness and prevent any potential adverse reactions. Lactated Ringer's solution is not commonly used for diluting phenytoin as normal saline solution is the preferred choice due to compatibility considerations.
Question 5 of 5
Which of the following terms indicates that the patient has a hearing loss caused by aging?
Correct Answer: B
Rationale: Presbycusis is the term that indicates that the patient has a hearing loss caused by aging. It is a type of sensorineural hearing loss that occurs gradually as a result of aging and affects the ability to hear high-pitched sounds. Otoplasty is a surgical procedure to correct the shape or position of the ears. Otalgia refers to ear pain. Tinnitus is the perception of ringing or buzzing sounds in the ears.