ATI RN
Nursing Care of Children ATI
1. An effective means of establishing rapport with the hospitalized pre-schooler is through:
- A. Lengthy discussion
- B. Explanation with drawings and models
- C. Play
- D. Silence
Correct answer: C
Rationale: Play is an effective way to communicate and build rapport with young children, especially pre-schoolers. It helps them feel comfortable, express themselves, and establish a connection with the caregiver. Lengthy discussions may not be suitable for their age and attention span, while explanation with drawings and models can enhance communication but may not engage them as effectively as play. Silence, on the other hand, may create a sense of unease or lack of interaction for pre-schoolers.
2. A client is receiving moderate sedation with Diazepam IV and is oversedated. Which of the following medications should the nurse anticipate administering to this client?
- A. Ketamine
- B. Naltrexone
- C. Flumazenil
- D. Fluvoxamine
Correct answer: C
Rationale: Flumazenil is a specific benzodiazepine antagonist that competitively reverses the sedative effects of benzodiazepines like Diazepam. In cases of oversedation or respiratory depression caused by benzodiazepines, administering Flumazenil can help reverse the effects and restore the client's consciousness and respiratory drive. Ketamine (Choice A) is a dissociative anesthetic and not used to reverse benzodiazepine sedation. Naltrexone (Choice B) is an opioid receptor antagonist and not indicated for benzodiazepine oversedation. Fluvoxamine (Choice D) is an antidepressant and not used to counteract benzodiazepine sedation.
3. In a normally functioning cardiovascular system, where does the heartbeat originate?
- A. Atrioventricular nodes
- B. Bundle of His
- C. Purkinje fibers
- D. Sinoatrial node
Correct answer: Sinoatrial node
Rationale: The correct answer is the Sinoatrial (SA) node. The SA node is known as the natural pacemaker of the heart as it initiates the electrical impulses responsible for the heartbeat. The other choices, such as the Atrioventricular (AV) nodes, Bundle of His, and Purkinje fibers, are involved in conducting the electrical signals generated by the SA node to coordinate the heart's contractions. Therefore, they do not serve as the primary origin of the heartbeat.
4. A client has been prescribed Phenelzine for depression. Which of the following indicates that the client has developed an adverse effect of this medication?
- A. Orthostatic hypotension
- B. Hearing loss
- C. Gastrointestinal bleeding
- D. Weight loss
Correct answer: A
Rationale: Orthostatic hypotension is a known adverse effect of Phenelzine, a monoamine oxidase inhibitor (MAOI) used for depression. It is caused by a sudden drop in blood pressure when changing positions, leading to symptoms like dizziness or fainting. Monitoring for orthostatic hypotension is crucial during Phenelzine therapy to prevent complications. Choices B, C, and D are incorrect because hearing loss, gastrointestinal bleeding, and weight loss are not typically associated with Phenelzine use.
5. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?
- A. Production of pink sputum
- B. Tracheal deviation
- C. Drainage greater than 70 mL/hr
- D. Sudden onset of shortness of breath
Correct answer: B
Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.