ATI Pediatrics Test Bank

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A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

  • A. Self-care deficient: Bathing/hygiene
  • B. Dysfunctional grieving
  • C. Ineffective cerebral tissue perfusion
  • D. Risk for injury
Correct Answer: C

Rationale: The nursing diagnosis that takes the highest priority for a client in a late stage of AIDS with signs of AIDS-related dementia is Ineffective cerebral tissue perfusion. This diagnosis is prioritized because AIDS-related dementia is associated with changes in brain function due to HIV affecting the brain tissues. Ensuring adequate cerebral perfusion is crucial to maintaining brain function and preventing further deterioration. Monitoring and addressing any factors that could affect cerebral perfusion, such as blood pressure, oxygenation, and circulation, are essential in managing this condition. Other nursing diagnoses are also important, but addressing ineffective cerebral tissue perfusion should be the highest priority in this situation to prevent further complications related to neurological function.

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A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?

  • A. tell the client to call for an analgesic before the pain felt becomes severe
  • B. encourage the patient to do leg exercises within the limits of his traction
  • C. provide an overhead trapeze for client use on the Balkan frame
  • D. provide skin care to prevent skin breakdown
Correct Answer: B

Rationale: Encouraging the patient to do leg exercises within the limits of his skeletal traction is the best nursing action to promote independence for the client. By engaging in leg exercises, the patient can maintain muscle strength and joint flexibility, which can prevent complications such as muscle atrophy and joint stiffness. This activity empowers the client to actively participate in their own care and promotes a sense of independence and control over their health during a period of immobility. Additionally, it can help improve circulation and prevent complications related to immobility such as deep vein thrombosis.

Mrs. Go is suspected of experiencing respiratory distress from a left-sided pneumothorax. She should be positioned:

  • A. in a semi-fowler's position
  • B. trendelenburg position
  • C. prone position
  • D. on the right side
Correct Answer: A

Rationale: Mrs. Go, who is suspected of experiencing respiratory distress from a left-sided pneumothorax, should be positioned in a semi-fowler's position. This position involves elevating the head of the bed to approximately 30 to 45 degrees. Placing the patient in a semi-fowler's position helps improve lung expansion, facilitates breathing, and promotes optimal oxygenation. It can also help prevent the collapse of the affected lung and assist in reducing the symptoms associated with pneumothorax. Trendelenburg position (B) and prone position (C) are not recommended for pneumothorax as they can worsen the condition by putting additional pressure on the affected lung. Placing the patient on the right side (D) would not specifically address the respiratory distress caused by a left-sided pneumothorax. Therefore, the most appropriate position for Mrs. Go in this situation is the semi-fowler's position.

When teaching umbilical cord care to a new mother, the nurse would include which information?

  • A. Apply peroxide to the cord with each diaper change
  • B. Cover the cord with petroleum jelly after bathing
  • C. Keep the cord dry and open to air
  • D. Wash the cord with soap and water each day during a tub bath
Correct Answer: C

Rationale: Keeping the cord dry and open to air is the recommended practice for umbilical cord care. This helps the cord to dry out and fall off naturally. Applying substances like peroxide or petroleum jelly can create a moist environment, which can increase the risk of infection. Washing the cord with soap and water daily can also prolong the time it takes for the cord to fall off. Thus, the best approach is to simply keep the cord clean and dry, allowing it to heal and detach on its own.

Which side effects should the nurse monitor when a child is taking an antipsychotic medication? (Select all that apply.)

  • A. Extrapyramidal effects
  • B. Hypertension
  • C. Bradycardia
  • D. Dizziness
Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

An adolescent teen has bulimia. Which assessment finding should the nurse expect to assess?

  • A. Diarrhea
  • B. Amenorrhea
  • C. Cold intolerance
  • D. Erosion of tooth enamel
Correct Answer: D

Rationale: Bulimia involves recurrent episodes of binge eating followed by compensatory behaviors such as vomiting. The frequent exposure of the teeth to stomach acid during vomiting can lead to erosion of tooth enamel. This can result in dental issues such as decay, sensitivity, and discoloration. Therefore, erosion of tooth enamel is a common assessment finding in individuals with bulimia. The other options (A. Diarrhea, B. Amenorrhea, C. Cold intolerance) are not typically associated with bulimia.

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