ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 of 5
Which of the following would the nurse use to document a finding that the patient's ear is draining?
Correct Answer: A
Rationale: Otorrhea is the medical term used to describe drainage from the ear. It is a finding that indicates the ear is draining fluid, which can be a sign of infection or other underlying issues. Otalgia refers to ear pain, ototoxic refers to substances that can damage the ear, and tinnitus refers to ringing in the ears. Therefore, otorrhea is the most appropriate term to document the finding of a draining ear.
Question 2 of 5
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
Correct Answer: C
Rationale: The signs and symptoms described - nausea, elevated temperature, tachycardia, and extreme restlessness - are indicative of a thyroid crisis, also known as thyroid storm. A thyroid storm is a life-threatening condition that can occur after thyroid surgery such as a subtotal thyroidectomy. It is characterized by an exaggerated state of hyperthyroidism, leading to a surge of thyroid hormones in the bloodstream. This can result in severe symptoms such as high fever, tachycardia, nausea, agitation, and even confusion or delirium.
Question 3 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 4 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 5 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.