ATI RN
Nursing Care of Children Final ATI
1. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)
- A. Reassessments
- B. Nursing care provided
- C. Initial assessments
- D. All of the above
Correct answer: D
Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.
2. Seizures are diagnosed by which of the following?
- A. Electroencephalogram (EEG) and ECG
- B. Seizure symptoms and complete blood count (CBC)
- C. Seizure symptoms and electrocardiogram (ECG)
- D. Seizure symptoms and EEG
Correct answer: D
Rationale: Seizures are most accurately diagnosed by EEG, which measures brain activity. Choice A is incorrect as ECG (electrocardiogram) measures heart activity, not brain activity. Choice B is incorrect as CBC (complete blood count) is a blood test and not used to diagnose seizures. Choice C is incorrect as an ECG (electrocardiogram) also measures heart activity, not brain activity, and is not the primary diagnostic tool for seizures.
3. The purpose of ECT in clients with depression is to:
- A. Stimulation in the brain to increase brain conduction and counteract depression
- B. Mainly Biologic, increasing the norepinephrine and serotonin level
- C. Creates a temporary brain damage that will increase blood flow to the brain
- D. Involves the conduction of electrical current to the brain to charge the neurons and combat depression
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
4. A client presents to the emergency department with complaints of chest pain and shortness of breath. The client's ECG shows ST-segment elevation. What is the priority nursing intervention?
- A. Administer aspirin as prescribed.
- B. Prepare the client for emergent coronary angiography.
- C. Administer oxygen therapy.
- D. Initiate CPR.
Correct answer: B
Rationale: In a client presenting with chest pain, shortness of breath, and ST-segment elevation on ECG, the priority nursing intervention is to prepare the client for emergent coronary angiography. This procedure is crucial in diagnosing and treating acute myocardial infarction promptly. Administering aspirin (Choice A) is important but not the priority over emergent coronary angiography. Administering oxygen therapy (Choice C) is supportive but does not address the underlying cause of the ST-segment elevation. Initiating CPR (Choice D) is not the priority in this scenario as the client is stable and conscious.
5. Clients may benefit from slightly higher fat intakes than are normally recommended if they have:
- A. congestive heart failure
- B. cerebrovascular accident
- C. peripheral vascular disease
- D. chronic obstructive pulmonary disease
Correct answer: D
Rationale: In chronic obstructive pulmonary disease (COPD), higher fat intake can be beneficial because it provides more calories with less respiratory burden compared to carbohydrates. Choices A, B, and C are incorrect because congestive heart failure, cerebrovascular accident, and peripheral vascular disease do not specifically benefit from higher fat intakes as in COPD.
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