ATI RN
RN Nursing Care of Children 2019 With NGN
1. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child?
- A. It is unnecessary because of child’s age.
- B. It is essential because it will be an adjustment.
- C. Preparation is not needed because the colostomy is temporary.
- D. Preparation is important because the child needs to deal with negative body image.
Correct answer: B
Rationale: Preparation is essential even for a young child, as they need to adjust to the temporary colostomy and understand the changes to their body, which can be confusing and distressing without proper explanation.
2. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?
- A. Insert a lubricated gloved finger and advance along the rectal wall
- B. Apply lubricant and stimulate peristalsis
- C. Apply pressure to the abdomen to assist with the removal
- D. Increase fluid intake before the procedure
Correct answer: A
Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.
3. The type of theory that discusses how motivation works to direct a person's efforts is:
- A. Reinforcement.
- B. Operant.
- C. Conditioning.
- D. Process.
Correct answer: D
Rationale: The correct answer is D, Process. Process theory focuses on how motivation directs an individual's efforts into performance. Reinforcement theory, on the other hand, views motivation as a form of learning. It involves operant conditioning, where behavior is associated with consequences. Conditioning is a broad term that includes both classical and operant conditioning, but it does not specifically address how motivation directs efforts. Therefore, choices A, B, and C are incorrect in the context of discussing how motivation works to direct a person's efforts.
4. Magnesium's major functions in the body would be least likely to include which of the following?
- A. allowing muscles to relax after contraction
- B. assisting the operation of hundreds of enzymes
- C. synthesis of protein in the soft tissues
- D. regulation of body temperature
Correct answer: D
Rationale: Magnesium plays a key role in muscle relaxation, enzyme operation, and protein synthesis, but it is not directly involved in regulating body temperature.
5. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?
- A. Diarrhea
- B. Hypermenorrhea
- C. Abnormal bleeding
- D. Abdominal distention
Correct answer: D
Rationale: Abdominal distention is a common symptom in advanced ovarian cancer due to several factors, including the accumulation of ascites (fluid in the abdominal cavity) and the presence of tumors that can increase abdominal girth. As the disease progresses, the pressure from growing masses or fluid buildup can lead to noticeable swelling and discomfort in the abdomen. This symptom often prompts further evaluation and can significantly impact the patient’s quality of life.
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