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: In a pediatric primary care setting, assessing motor functions during a neurologic examination is crucial for evaluating developmental milestones and detecting any abnormalities early on. Option A, allowing the client to grasp the nurse's hand firmly, is the correct choice because it assesses grip strength, coordination, and muscle tone, providing valuable information about motor function. Option B, checking sensitivity to various stimuli, is more related to sensory function rather than motor function. This step would not directly contribute to assessing motor skills in a neurologic examination. Option C, asking the client to pick up small and large objects between the thumb and forefinger, is more specific to fine motor skills and hand-eye coordination rather than a comprehensive motor function assessment. Option D, asking questions that require cognition and logic, is more aligned with testing cognitive function rather than motor skills, thus not directly relevant to a neurologic examination focusing on motor functions. In an educational context, understanding the rationale behind each step of a neurologic examination is essential for nurses to accurately assess a child's motor function and identify any developmental delays or concerns. By choosing the appropriate assessment techniques, nurses can provide comprehensive care and support to pediatric patients.
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.