ATI RN
ATI Nursing Care of Children
1. A school-age child is admitted to the pediatric unit with a vaso-occlusive crisis. Which of these should be included in the nursing plan of care?
- A. Correction of alkalosis
- B. Pain management and administration of heparin
- C. Adequate oxygenation and replacement of factor VIII to correct the sickling
- D. Adequate hydration, oxygenation, and pain management
Correct answer: D
Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia require a comprehensive approach that includes adequate hydration to reduce blood viscosity, oxygenation to prevent further sickling of red blood cells, and aggressive pain management. This approach helps improve tissue perfusion and manage pain effectively. Choices A, B, and C are incorrect. Correction of alkalosis is not a priority in vaso-occlusive crisis management. Administration of heparin is not indicated as it can increase the risk of bleeding in sickle cell patients. Factor VIII replacement is not relevant to sickle cell anemia as it is a treatment for hemophilia, not sickle cell disease.
2. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse implement?
- A. Massage the client's legs every 2 hours.
- B. Encourage the client to remain on bed rest.
- C. Apply sequential compression devices to the client's legs.
- D. Administer anticoagulants as prescribed.
Correct answer: C
Rationale: The correct action the nurse should implement is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis and reduce the risk of deep vein thrombosis (DVT). Massaging the client's legs may dislodge a clot and is contraindicated in this situation (choice A). Encouraging bed rest may increase the risk of DVT due to prolonged immobility (choice B). While administering anticoagulants is a common treatment for DVT, in this case, the question is about preventive measures, and using sequential compression devices is a non-pharmacological approach.
3. A client has been prescribed fluoxetine (Prozac) for the treatment of depression. Which of the following instructions should the nurse include in the discharge instructions?
- A. Take the medication at bedtime to avoid daytime drowsiness.
- B. Avoid drinking alcohol while taking this medication.
- C. Take the medication with a full glass of water.
- D. Stop taking the medication if you feel better.
Correct answer: B
Rationale: The correct answer is B. The nurse should instruct the client to avoid drinking alcohol while taking fluoxetine (Prozac) because alcohol can increase the risk of side effects such as drowsiness and dizziness. It is important to follow this instruction to ensure the safe and effective use of the medication in the treatment of depression. Choice A is incorrect because fluoxetine (Prozac) is usually taken in the morning to prevent insomnia. Choice C is not a crucial instruction for this medication. Choice D is incorrect as abruptly stopping fluoxetine can lead to withdrawal symptoms and should only be done under medical supervision.
4. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
- A. The passage of flatus
- B. Absent bowel sounds
- C. The client’s ability to tolerate food
- D. Bloody drainage from the colostomy
Correct answer: A
Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It’s a positive sign that the bowel is recovering from the surgery and starting to work as intended.
5. Which statement reflects an accurate understanding of the concepts of mental health and mental illness?
- A. The concepts are rigid and religiously based.
- B. The concepts are multidimensional and culturally defined.
- C. The concepts are universal and unchanging.
- D. The concepts are unidimensional and fixed.
Correct answer: B
Rationale: Understanding mental health and mental illness as multidimensional and culturally defined is essential for healthcare professionals. Mental health varies across cultures and is influenced by various dimensions such as biological, psychological, social, and spiritual factors. Recognizing these differences helps in providing culturally competent care and understanding the diverse expressions of mental health and illness. Choice A is incorrect because mental health and mental illness are not rigid or solely based on religion. Choice C is incorrect because mental health and mental illness are not universally experienced in the same way and can change over time. Choice D is incorrect because mental health and mental illness are not unidimensional; they involve various factors and are not fixed in nature.