ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
Which of the following dietary interventions prevents the precipitation of calcium renal stones?
Correct Answer: C
Rationale: High fluid intake is the dietary intervention that prevents the precipitation of calcium renal stones. By increasing fluid intake, particularly water, the urine gets diluted, thus reducing the concentration of substances that can lead to the formation of kidney stones, including calcium. Drinking enough water can also help to flush out any potential stone-forming minerals or substances before they have a chance to crystallize and form stones in the kidney. It is recommended to have an adequate fluid intake of around 2 to 3 liters per day to reduce the risk of calcium stone formation in the kidneys. High fiber diet, increased protein intake, and intake of zinc do not directly prevent the precipitation of calcium renal stones as effectively as maintaining high fluid intake.
Question 2 of 5
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
Correct Answer: B
Rationale: Using pressure relieving devices when the client is in bed is essential to prevent skin breakdown. Clients with neuromuscular disorders are at higher risk for impaired skin integrity due to limited mobility and sensation. Pressure relieving devices such as specialized mattresses, cushions, or pads help distribute pressure evenly and reduce the risk of pressure ulcers. Maintaining good skin integrity is crucial in preventing complications and promoting the overall well-being of the client. It is important for the nurse to assess the client's risk factors, implement preventive measures like using pressure relieving devices, and monitor the client's skin regularly to prevent skin breakdown.
Question 3 of 5
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
Correct Answer: D
Rationale: Administering edrophonium (Tensilon) to a client with myasthenia gravis helps differentiate between cholinergic crisis and myasthenic crisis. In cholinergic crisis, which is caused by excessive acetylcholine levels due to an overdose of anticholinesterase medications, the client may experience a temporary worsening of symptoms such as muscle weakness, respiratory distress, and other cholinergic effects. This temporary worsening is due to the increase in acetylcholine levels, leading to overstimulation of nicotinic and muscarinic receptors. On the other hand, in myasthenic crisis, which is caused by insufficient acetylcholine at the neuromuscular junction, administering edrophonium would lead to an improvement in muscle weakness. Therefore, if the client experiences a temporary worsening of symptoms after receiving edrophonium, it indicates cholinergic crisis.
Question 4 of 5
Which of the following tests would the nurse use as an initial screening test to determine hearing loss?
Correct Answer: D
Rationale: The nurse would use the whisper voice test as an initial screening test to determine hearing loss. This test involves the nurse whispering a series of words or numbers from a distance behind the patient to assess their ability to hear and repeat the whispered words accurately. This test is quick, easy, and can be performed in a quiet environment without the need for special equipment, making it an effective initial screening tool for hearing loss. The Romberg test assesses balance, the caloric test evaluates vestibular function, and the otoscopic examination is used to assess the external ear canal and eardrum, but none of these tests specifically assess hearing loss.
Question 5 of 5
Which of the ff. type of eyedrops does the nurse understand is given to constrict the pupil, permitting aqueous humor to flow around the lens?
Correct Answer: B
Rationale: Mydriatic eye drops are used to dilate or enlarge the pupil. By dilating the pupil, these eye drops allow more light to enter the eye and are often used before eye exams. This dilation also permits aqueous humor to flow around the lens. In contrast, myotic eye drops are used to constrict the pupil, which can increase pressure in the eye. Osmotic eye drops are used to reduce intraocular pressure by drawing fluid out of the eye. Cycloplegic eye drops are used to temporarily paralyze the muscles in the eye, affecting accommodation and pupil size.