ATI LPN
ATI NS122 Pediatrics Monroe College NY PN Questions
Extract:
Question 1 of 5
The nurse is caring for a 7-year-old child who fell off an ATV sustaining a flesh wound. The child is awaiting wound debridement. What nursing action best demonstrates the concept of atraumatic care?
Correct Answer: B
Rationale: Allowing siblings to visit the client in the hospital - Allowing siblings to visit the client in the hospital is a compassionate gesture and promotes family-centered care. However, it may not directly address the concept of atraumatic care, which focuses on minimizing physical and psychological stress related to healthcare procedures. Using a doll to demonstrate an invasive procedure - Using a doll to demonstrate an invasive procedure is an example of atraumatic care. It allows the nurse to provide preparatory information to the child in a non-threatening and understandable manner. By visually demonstrating the procedure on a doll, the child can better understand what will happen, reducing anxiety and fear. Encouraging communication between the parents and nurse - Encouraging communication between the parents and nurse is important for providing holistic care and addressing the child's needs. While effective communication is essential, it may not directly demonstrate the concept of atraumatic care unless it involves discussing how to minimize stress and anxiety during procedures. Arranging the room to accommodate religious practices - Arranging the room to accommodate religious practices is a form of patient-centered care and respects the cultural and religious beliefs of the patient and family. While important for overall comfort and respect for the patient's values, it may not directly relate to the concept of atraumatic care, which specifically focuses on reducing stress and anxiety during healthcare procedures.
Question 2 of 5
A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
Correct Answer: B
Rationale: Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
Question 3 of 5
A nurse is caring for a child who has Hirschsprung disease. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Ridged abdomen - This finding is not typically associated with Hirschsprung disease. Instead, the abdomen may appear distended or bloated due to the accumulation of stool in the colon. Ribbonlike, foul-smelling stools - This is a characteristic finding in Hirschsprung disease. Because the affected portion of the colon lacks nerve cells (ganglion cells) responsible for peristalsis, stool movement is impaired, leading to the passage of narrow, ribbonlike stools. These stools may also have a foul odor due to bacterial overgrowth in the affected area. Projectile vomiting - Projectile vomiting is not a common finding in Hirschsprung disease. It is more commonly associated with conditions such as pyloric stenosis or gastroesophageal reflux. Chronic hunger - Chronic hunger is not a typical finding in Hirschsprung disease. Instead, affected infants may experience feeding difficulties, constipation, and failure to thrive due to the obstruction of stool in the colon. They may also exhibit symptoms such as abdominal distention, vomiting, and refusal to feed.
Question 4 of 5
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: While some parents may prefer cloth diapers, they can retain moisture and irritants. Disposable diapers with good absorbency are often preferred in managing diaper dermatitis. Using a gentle moisturizer to clean the skin can help protect the infant's skin and maintain its barrier function, especially in cases of diaper dermatitis. Moisturizers help soothe and heal the affected area by providing hydration and protection. Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues. Additionally, powders can clump and worsen skin irritation. Exposing the skin to hot air can dry out the skin and worsen irritation. It's better to allow the area to air-dry naturally or use a cool blow dryer on a low setting.
Question 5 of 5
A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect:
Correct Answer: C
Rationale: Gross hematuria: Gross hematuria refers to visible blood in the urine, which can present as pink, red, or cola-colored urine. While hematuria can be associated with various kidney conditions, including Wilms' tumor, it is not a consistent or defining symptom of this specific tumor. Additionally, because the tumor is typically confined within the kidney and does not usually invade the urinary tract, gross hematuria might not always be present. Dysuria: Dysuria is the medical term for painful or difficult urination. It is not a typical symptom of Wilms' tumor, as this tumor primarily affects the kidney and may not directly affect the urinary tract in a way that causes painful urination. An abdominal mass: This is the correct answer. Wilms' tumor often presents as a palpable abdominal mass, which may be felt during physical examination. The mass is usually firm, non-tender, and confined to one side of the abdomen. Detection of an abdominal mass should prompt further diagnostic evaluation to confirm the diagnosis and plan appropriate treatment. Nausea and vomiting: While some children with Wilms' tumor may experience nausea and vomiting, these symptoms are nonspecific and can be caused by various conditions. They are not considered characteristic or defining features of Wilms' tumor. The presence of nausea and vomiting would prompt further assessment to determine the underlying cause.