ATI LPN
ATI NS122 Pediatrics Monroe College NY PN Questions
Extract:
Question 1 of 5
You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)
Correct Answer: B,D,E
Rationale: A. Bed in highest position: The height of the bed is not directly related to seizure precautions. B. Remove restrictive objects or clothing from patient's body: This is important to prevent injury during a seizure episode. C. Remove all pillows from the patient's head: While it's generally a good practice to remove pillows to prevent suffocation or obstruction, it's not specifically related to seizure precautions. D. Oxygen and suction at bedside: Oxygen and suction should be readily available to support the patient's respiratory status and clear any secretions or vomit during or after a seizure. E. Padded bed rails: Padded bed rails can help prevent injury if the patient thrashes or moves violently during a seizure.
Question 2 of 5
Bacterial infection caused by both staph and strept bacteria. Usually sign around mouth and nose, more common in children and the elderly.
Correct Answer: D
Rationale: Eczema: Eczema is a chronic skin condition characterized by inflammation, redness, and itching. It is not typically caused by bacterial infections and does not present with signs around the mouth and nose. Vitiligo: Vitiligo is a condition characterized by the loss of skin color in patches. It is not caused by bacterial infections and does not typically present with signs around the mouth and nose. Angioedema: Angioedema is swelling beneath the skin, often around the eyes and lips, and is commonly associated with allergic reactions or other triggers. It is not caused by bacterial infections. Impetigo: Impetigo is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes bacteria. It commonly presents with red sores or blisters around the mouth and nose, especially in children and the elderly.
Therefore, option D, Impetigo, is the correct answer.
Question 3 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 4 of 5
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Place the child in a side-lying position. This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs. Restrain the child's arms. Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure. Elevate the child's legs on a pillow. Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury. Insert a padded tongue blade into the child's mouth. Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.
Question 5 of 5
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: C,
Rationale: A. Place a tongue depressor in the child's mouth: This is an incorrect action. Placing a tongue depressor or any other object in the child's mouth during a seizure can cause injury to the child's mouth, teeth, or airway. It may also increase the risk of choking. It's a common misconception that people can swallow their tongues during a seizure, but this is not true. It's important to keep the child's mouth clear of objects and allow the seizure to run its course. B. Restrain the child: This is also an incorrect action. Restraint can cause further injury to the child and increase agitation, which may worsen the seizure. It's important to allow the child to move freely during a seizure while taking steps to ensure their safety, such as clearing the area of objects and protecting the head from injury. C. Clear the area of hard objects: This is a correct action. Removing hard objects from the area helps prevent injury to the child during a seizure. Objects such as furniture corners or sharp items can pose a risk if the child thrashes or moves unpredictably during the seizure. D. Loosen restrictive clothing: This is also a correct action. During a seizure, it's important to ensure that the child's clothing is not too tight or restrictive. Loosening clothing, especially around the neck and chest area, helps ensure adequate airflow and prevents restriction of movement during the seizure. E. Place the child in a prone position: This is an incorrect action. Placing the child in a prone (face-down) position during a seizure can increase the risk of airway obstruction and make it more difficult for the child to breathe. Instead, the child should be placed on their side (recovery position) to help maintain an open airway and prevent aspiration if vomiting occurs.