ATI RN
ATI Pediatrics Exam 1 Questions
Extract:
A client with a C3 spinal cord injury.
Question 1 of 5
When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?
Correct Answer: C
Rationale: Counting respirations is critical for a C3 injury due to phrenic nerve involvement, risking respiratory failure. Urinary output, blood pressure, and bowel sounds are secondary.
Extract:
A client with tetanus.
Question 2 of 5
When educating a client about tetanus, which of the following will the nurse include in teaching? Select All that Apply
Correct Answer: B,E
Rationale: Tetanus causes sustained muscle contractions and is transmitted via spores in soil, gardens, or manure. It affects the nervous system broadly, not just the spinal cord, and is bacterial, not viral or food-related.
Extract:
A client with a spinal cord injury reporting hot, burning, tingling pain shooting down extremities.
Question 3 of 5
A client with a spinal cord injury reports hot, burning, tingling, pain that shoots down his extremities. When the client asks why this occurs, what is the nurse's best response?
Correct Answer: C
Rationale: Neuropathic pain from nerve damage in the spinal cord causes burning, tingling sensations. Repositioning, inflammation, or a 2-week resolution are incorrect explanations.
Extract:
A client with partial paralysis repositioned to a side-lying position.
Question 4 of 5
A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?
Correct Answer: C
Rationale: Placing a pillow between knees and ankles prevents pressure ulcers and skin breakdown in a side-lying position. Measuring calves, palpating the bladder, or checking the gag reflex are unrelated to repositioning complications.
Extract:
An older adult client with dementia who handles anxiety by confabulating.
Question 5 of 5
A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize which of the following as confabulation?
Correct Answer: A
Rationale: Confabulation involves making up stories to fill memory gaps, a common dementia behavior. Reminiscing, compulsive behaviors, or refusal to leave home are distinct phenomena.