when assessing a 30 year old female who was sexually assaulted it is most important for you to
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Nursing Elites

ATI LPN

ATI Pediatrics Proctored Test

1. When assessing a 30-year-old female who was sexually assaulted, what is the MOST important action for you to take?

Correct answer: D

Rationale: In cases of sexual assault, the priority is to address any life-threatening injuries first before proceeding with other aspects of care. Although preserving evidence and approaching the situation with sensitivity are crucial, immediate treatment of life-threatening conditions takes precedence to ensure the patient's well-being and safety. Having a female healthcare provider, advising against showering or changing clothes, and acknowledging the patient as a potential crime scene are important but secondary considerations compared to addressing any life-threatening injuries promptly.

2. A 2-year-old client is admitted for an acute asthma episode. The hospital provides family-centered care. In explaining the program to the parents, the nurse would explain that the parents are:

Correct answer: B

Rationale: Family-centered care involves encouraging parents to actively participate in their child's care based on their comfort level. This approach promotes collaboration between healthcare providers and families, enhancing the quality of care and ensuring the family's involvement in decision-making. Choice A is incorrect because parents are encouraged to participate, not required to implement all personal hygiene care. Choice C is incorrect as it implies a specific action rather than the broader concept of involvement. Choice D is incorrect as it focuses solely on physical presence rather than active participation in care.

3. A child newly diagnosed with diabetes mellitus has been stabilized with insulin injections daily. A nurse prepares a discharge teaching plan regarding the insulin. The teaching plan should reinforce which of the following concepts?

Correct answer: D

Rationale: Systematically rotating injection sites is crucial to prevent tissue damage and ensure optimal insulin absorption. This practice helps in preventing lipohypertrophy, a condition characterized by fat accumulation at injection sites, which can affect insulin absorption and lead to inconsistent blood glucose control. By rotating injection sites, the risk of skin and tissue damage is minimized, and insulin's effectiveness is maintained over time.

4. When assessing a 5-year-old boy with major trauma, his blood pressure is 70/40 mm Hg, and his pulse rate is 140 beats/min and weak. The child's blood pressure:

Correct answer: A

Rationale: In a 5-year-old boy with major trauma, a blood pressure of 70/40 mm Hg and a pulse rate of 140 beats/min, and weak, indicate decompensated shock. This presentation signifies inadequate perfusion, leading to compensatory mechanisms being overwhelmed, resulting in decompensated shock. Choice B is incorrect as the vital signs suggest the body is unable to adequately compensate for the trauma. Choice C is incorrect as the vital signs are more indicative of shock rather than increased intracranial pressure. Choice D is incorrect as such low blood pressure is not appropriate for a child of this age and indicates a critical condition.

5. A 4-year-old boy ingested an unknown quantity of drain cleaner. He is alert, has a patent airway, and has adequate breathing. You should:

Correct answer: C

Rationale: When a child ingests a harmful substance like drain cleaner and remains alert with a patent airway and adequate breathing, the initial steps involve contacting poison control to guide further management. In this scenario, providing oxygen to support respiratory function is essential until definitive care is established. Activated charcoal and ipecac are not recommended in the management of ingested caustic substances like drain cleaner. Performing a head-to-toe exam can wait until the child's immediate respiratory needs are addressed and the poison control center has provided guidance on further management.

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