ATI RN
RN Nursing Care of Children 2019 With NGN
1. What do the clinical manifestations of minimal change nephrotic syndrome include?
- A. Hematuria, bacteriuria, and weight gain
- B. Gross hematuria, albuminuria, and fever
- C. Hypertension, weight loss, and proteinuria
- D. Massive proteinuria, hypoalbuminemia, and edema
Correct answer: D
Rationale: Minimal change nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema due to the loss of protein in the urine. Hematuria, bacteriuria, and weight loss are not typical features of this condition.
2. A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?
- A. Place the client in droplet isolation.
- B. Place the client in airborne isolation.
- C. Wear a surgical mask when providing care to the client.
- D. Keep the client's door closed at all times.
Correct answer: B
Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.
3. A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?
- A. Evaluate the client's gag reflex.
- B. Assess the client's bowel sounds.
- C. Check the client's pupil reaction.
- D. Monitor the client's heart rate.
Correct answer: A
Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.
4. How can the nurse best explain the difference between angina and a myocardial infarction to a client presenting with severe chest pain?
- A. “Angina usually resolves with rest, and is rarely fatal, while a myocardial infarction necessitates immediate treatment and can be life-threatening.”
- B. “There is a clear distinction between the two. You will receive treatment based on the diagnosis of a myocardial infarction.”
- C. “Both conditions result from a clot obstructing the coronary arteries. Angina occurs with the blockage of a small vessel, whereas a myocardial infarction occurs with a blockage of a large vessel.”
- D. “Angina may not cause as intense chest pain, whereas a myocardial infarction always presents with severe chest pain.”
Correct answer: A
Rationale: When educating a client about the differences between angina and a myocardial infarction, it is crucial to emphasize key distinguishing factors. Angina typically improves with rest and is not usually life-threatening, whereas a myocardial infarction requires urgent intervention as it can be life-threatening. This explanation helps the client understand the urgency and severity associated with a myocardial infarction compared to angina.
5. What structure separates the left and right sides of the heart?
- A. Interventricular septum
- B. Endocardium
- C. Epicardium
- D. Pericardium
Correct answer: A
Rationale: The interventricular septum is the correct answer as it is the wall that separates the left and right sides of the heart, ensuring the oxygenated and deoxygenated blood do not mix. The endocardium is the inner lining of the heart chambers, the epicardium is the outermost layer of the heart wall, and the pericardium is the sac that surrounds the heart, providing protection and anchoring the heart in place. Therefore, choices B, C, and D are incorrect in the context of separating the left and right sides of the heart.
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