ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
Which of the following settings is most therapeutic for an agitated head-injured patient?
Correct Answer: B
Rationale: For an agitated head-injured patient, the most therapeutic setting would be a semiprivate room with one or two consistent caregivers. Consistency and familiarity can help reduce agitation and promote a sense of security for the patient. A quieter environment with fewer stimuli can also help in managing agitation and promoting a sense of calmness. By having consistent caregivers, the patient can build trust and feel more comfortable, which can contribute to their overall well-being and recovery. It is essential to minimize external factors that could contribute to further agitation, making a semiprivate room with consistent caregivers the most optimal setting for an agitated head-injured patient.
Question 2 of 5
During the physical examination of a client for a possible neurologic disorder, how can the nurse examine the client for stiffness and rigidity of the neck?
Correct Answer: B
Rationale: The nurse can examine the client for stiffness and rigidity of the neck by moving the head and chin of the client toward the chest. This maneuver, known as neck flexion, assesses the resistance and presence of stiffness in the neck muscles. Stiffness and rigidity of the neck muscles may suggest conditions such as meningitis, cervical dystonia, or other neurologic disorders. It is important for the nurse to perform this examination maneuver carefully to avoid causing discomfort or injury to the client.
Question 3 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 4 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 5 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.