the nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism which assessment finding most likely related to
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam 2023

1. The patient is receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding is most likely related to an adverse effect of heparin?

Correct answer: C

Rationale: The primary and most serious adverse effect of heparin is bleeding. However, discolored urine can indicate bleeding into the urinary tract, which is a potential adverse effect of heparin therapy. While changes in heart rate (HR) and blood pressure (BP) can occur due to various reasons, discolored urine specifically points towards a potential adverse effect related to heparin therapy.

2. A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data?

Correct answer: D

Rationale: In bacterial meningitis, the glucose level in the cerebrospinal fluid (CSF) is typically decreased due to the increased utilization of glucose by the infecting bacteria. This metabolic change leads to a decrease in CSF glucose levels, making choice D the correct answer in this scenario. Choices A, B, and C are incorrect because bacterial meningitis usually results in an increased protein count, cloudy appearance of the CSF due to the presence of bacteria, and absence of red blood cells (RBCs) in the CSF unless there is a traumatic tap, respectively.

3. Why is it important to share information with the family about why you are asking certain things as you evaluate the child?

Correct answer: A

Rationale: Sharing information with the family about the reasons for your questions is crucial as it helps them comprehend the purpose and role of occupational therapy in the evaluation process. This transparency fosters trust, collaboration, and empowers families to actively engage in the therapy journey. Choice B is incorrect because while it is essential to establish goals with the family, the focus here is on sharing information about the evaluation process. Choice C is incorrect as the main purpose is not to showcase expertise but rather to involve the family in understanding the assessment. Choice D is incorrect as the primary goal is not for the family to understand your point of view, but rather the purpose of the evaluation within the occupational therapy context.

4. Which assessment data would cause suspicion that a 3-year-old child has Hirschsprung disease?

Correct answer: C

Rationale: Hirschsprung disease is characterized by chronic, progressive constipation and failure to gain weight. These symptoms are indicative of the disorder due to the absence of ganglion cells in the distal colon, leading to impaired motility and obstruction.

5. When teaching a parent of a child with contact dermatitis, which instruction should the nurse include?

Correct answer: D

Rationale: The correct instruction for a child with contact dermatitis is to apply a thin layer of corticosteroid cream to the affected area. Corticosteroid cream helps reduce inflammation and itching associated with contact dermatitis. It is important to avoid using antibiotic ointment or rubbing the skin vigorously, as these can worsen the condition. Keeping the child's skin dry is generally a good practice, but in the case of contact dermatitis, corticosteroid cream application is more beneficial.

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