ATI RN
Nursing Care of Children ATI
1. A 10-month-old infant is diagnosed with gastroesophageal reflux. An esophageal (pH) probe monitor is ordered. What explanation for the purpose of the esophageal probe should the nurse provide to the parents?
- A. Assist in the passage of formula through the esophagus
- B. Identify the number of reflux episodes that are occurring
- C. Determine the time it takes for the stomach to empty its contents
- D. Monitor the pH within the stomach
Correct answer: B
Rationale: The correct answer is B. The esophageal pH probe is used to identify the frequency and severity of reflux episodes by measuring the pH in the esophagus. Choice A is incorrect because the probe does not assist in the passage of formula through the esophagus. Choice C is incorrect as determining the time it takes for the stomach to empty its contents would require a different procedure. Choice D is incorrect as the esophageal pH probe monitors the pH in the esophagus, not the stomach.
2. When assessing for potential signs and symptoms of cryptococcosis in a patient with HIV being treated with Amphotericin B, the nurse should prioritize what assessment?
- A. Neurological assessment
- B. Functional assessment
- C. Nutritional assessment
- D. Cardiac assessment
Correct answer: A
Rationale: In a patient with cryptococcosis and HIV, neurological assessment should be prioritized because cryptococcosis commonly affects the central nervous system, leading to symptoms such as headache, confusion, and altered mental status. This assessment is crucial in monitoring for any neurological complications and guiding appropriate interventions. Functional assessment focuses on the patient's ability to perform activities of daily living and is not directly associated with cryptococcosis. Nutritional assessment is important for overall health but is not the priority when assessing for cryptococcosis. Cardiac assessment is not a priority in cryptococcosis as the primary manifestations are related to the central nervous system.
3. What principle about patient-nurse communication should guide a nurse's fear of saying the wrong thing to a patient?
- A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
- B. Patients are more interested in conversing with you than in hearing your perspective, making offense unlikely.
- C. Considering the patient's background, the likelihood of the comment causing harm is minimal.
- D. Individuals with mental illness often possess a heightened capacity for forgiveness.
Correct answer: A
Rationale: The correct answer is A. Patients value interactions with healthcare providers who express genuine acceptance, respect, and concern for their well-being. By focusing on conveying these qualities, a nurse can help alleviate fears of saying the wrong thing as patients appreciate the sincerity and empathy in the communication. This approach fosters trust and a positive therapeutic relationship, enhancing the effectiveness of patient-nurse communication.
4. Which endocrine disorder would the nurse assess for in the client who has a closed head injury with increased intracranial pressure?
- A. Pheochromocytoma
- B. Diabetes insipidus
- C. Hashimoto's disease
- D. Gynecomastia
Correct answer: B
Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (Choice A) is a tumor of the adrenal gland that causes excessive release of catecholamines, leading to hypertension. Hashimoto's disease (Choice C) is an autoimmune condition affecting the thyroid gland. Gynecomastia (Choice D) refers to the enlargement of breast tissue in males and is not directly related to a closed head injury with increased intracranial pressure.
5. A client with breast cancer is being taught about Tamoxifen. Which of the following adverse effects of tamoxifen should the client be informed about?
- A. Irregular heart rhythm
- B. Abnormal uterine bleeding
- C. Yellowing of the sclera or dark-colored urine
- D. Difficulty swallowing
Correct answer: B
Rationale: Abnormal uterine bleeding is a known adverse effect of tamoxifen. It is important to educate the client about this side effect as those taking tamoxifen are at an increased risk for endometrial cancer. Any abnormal uterine bleeding should be promptly reported and evaluated by healthcare providers to ensure timely management and monitoring. The other options, such as irregular heart rhythm, yellowing of the sclera or dark-colored urine, and difficulty swallowing, are not typically associated with tamoxifen use and are not commonly reported adverse effects. Therefore, they are not the priority adverse effects to inform the client about.