ATI RN
RN Nursing Care of Children 2019 With NGN
1. The nurse is caring for an adolescent who has just started dialysis. The child always seems angry, hostile, or depressed. The nurse should recognize that this is most likely related to what underlying cause?
- A. Physiologic manifestations of renal disease
- B. The fact that adolescents have few coping mechanisms
- C. Neurologic manifestations that occur with dialysis
- D. Resentment of the control and enforced dependence imposed by dialysis
Correct answer: D
Rationale: Adolescents may feel anger and depression due to the loss of independence and control over their lives, which is imposed by the need for regular dialysis treatments. This reaction is common as they struggle with the restrictions placed on their social and personal lives.
2. The nurse is planning care for a client with damage to the vestibular area of the vestibulocochlear nerve. What should the nurse include in the plan of care? Select all that apply.
- A. Assistance with ambulation
- B. Regular hearing tests
- C. Monitoring for nausea
- D. Vision assessments
Correct answer: A
Rationale: Damage to the vestibular area affects balance and may cause nausea. Therefore, the nurse should include assistance with ambulation in the care plan to help the client maintain stability while walking. Regular hearing tests (choice B) are not directly related to damage in the vestibular area of the vestibulocochlear nerve. While nausea (choice C) may occur due to vestibular damage, monitoring for it alone is not as essential as providing assistance with ambulation. Vision assessments (choice D) are important for assessing visual function but are not the priority when dealing with vestibular issues.
3. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?
- A. Restrict the patient's fluid intake.
- B. Monitor the patient's daily weight.
- C. Administer diuretics as prescribed.
- D. Increase the patient's salt intake to promote fluid balance.
Correct answer: B
Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.
4. While caring for a client on long-term aspirin therapy, the nurse should monitor the client for which of the following complications?
- A. Hemorrhagic stroke
- B. Thromboembolic stroke
- C. Iron deficiency anemia
- D. Neutropenia
Correct answer: A
Rationale: Corrected Rationale: Long-term aspirin therapy can increase the risk of hemorrhagic stroke due to its antiplatelet effects, which can lead to bleeding complications. Aspirin inhibits platelet function, potentially causing bleeding in the brain and increasing the risk of a hemorrhagic stroke. Choice B, thromboembolic stroke, is incorrect because aspirin therapy is actually used to prevent thromboembolic events by inhibiting platelet aggregation. Choices C and D, iron deficiency anemia and neutropenia, are not directly associated with long-term aspirin therapy.
5. The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to
- A. Eat a good supper when anorexia is not as severe.
- B. Eat less often, preferably only three large meals daily.
- C. Increase intake of fluids including juices.
- D. Select foods high in fat.
Correct answer: C
Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with low-fat content because fat may be tolerated poorly due to decreased bile production. Small, frequent meals are preferable and may prevent nausea. Appetite is often better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is also important.
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