ATI NURS MISC Practice Exam Rationales
Maternal
True labor:
- Client should feel contractions primarily in the lower abdomen and back
- Cervix tran
... [Show More] sitions to an anterior position and begins to dilate in preparation for birth
- Contraction intensity increases with ambulation
- Cervix progressively shortens and thins
Children’s
Findings to expect for a toddler with cerebral palsy:
- Ankle clonus (rhythmic reflex tremor when the foot is dorsiflexed)
- Exaggerated stretch reflexes
- Contractures due to the tightening of the muscles Interventions for an adolescent getting a lumbar puncture:
- Apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent’s pain while the needle is inserted
- The nurse should place the adolescent in the prone position or flat in bed for up to 12 hr
following the procedure to prevent postprocedural spinal headache
- The nurse should encourage the adolescent to drink extra fluid following the procedure to replace the CSF removed during the procedure
Normal VS for a 3 year old toddler:
- BP range 86-118 systolic; 44-74 diastolic
- RR range 20-25/min
- HR range 80-120 bpm
What findings should the nurse identify as an indication that the child is developing SIADH following a head injury?
- Mental confusion (as a result of altered pituitary fx)
- Decrease in urine output
- Hyponatremia
- Hypoosmolality due to overhydration
- Seizures
An allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine
Car seat safety:
- Low anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant’s car seat in the vehicle. This system provides anchors between the front cushion and the backrest for the car seat. Therefore, if this system is available, the seat belt does not have to be used
- The car seat harness in rear facing car seats should be positioned at or just below the infant's shoulders
- The car seat should be positioned at a 45 degree angle to prevent slumping and injury to the infant
- Padding placed underneath the infant or anywhere in the car seat can compress and/or
create space between the infant and the harness. This can increase the risk for injury to the infant and should be avoided
After performing a lumbar puncture, what finding should the nurse identify as an indication of bacterial meningitis?
- An increased protein concentration in the CSF
- Decreased glucose level
- Increased WBC count
- Increased CSF pressure
Actions to take while caring for a toddler who has a partial thickness burn on their arm:
- Wash the affected area with mild soap and water to remove any loose tissue that could cause infection
- Apply antimicrobial ointment to the affected area to prevent infection
- Be aware that antibiotics are not routinely administered for the prevention of infection at the burn site because the decreased circulation in the burned area decreased the distribution of the medication to the deeper tissues
- NG tube placement is only used for major burn management (not partial thickness) Foods to provide to a school age child with celiac disease:
- White rice can be offered to a child w/ celiac disease bc it is gluten free
- Avoid oats, rye, barley, wheat
- Celiac disease can be accompanied w/ lactose deficiency
The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease
Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment.
The nurse should monitor the adolescent’s serum potassium level following the administration of a sodium polystyrene sulfonate enema. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore a potassium level within the expected range of 3.4 to 4.7 indicates the effectiveness of the medication
For a child who has a tunneled central venous access device, the nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection
Instructions for a parent with moderate persistent asthma:
- Beta2 agonists are to be used in conjunction with a low or medium dose inhaled corticosteroid, and never used alone. Using this medication alone on an as needed basis
during an acute asthma attack is dangerous and can lead to worsening of the child's condition
- Inform the parents that their child will need pulmonary function tests every 12 to 24
months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly
- Measure the child’s airflow using a peak expiratory flow meter. This should be done twice daily, taking three measurements each time and waiting 30 seconds between each measurement. The parents should record the highest of the three readings, rather than the average
Manifestations of intussusception:
- Bloody stools that are currant jelly-like in appearance
- Exhibit vomiting due to the obstruction that occurs when a segment of the bowl telescopes within another segment of the bowel
- Exhibit lethargy due to episodes of severe pain during which the infant cries
inconsolably, leading to exhaustion and decreased nutritional intake
- Mucus-filled and red jelly like diarrhea due to the leaking of blood and mucus into the intestinal lumen
- Weight loss due to anorexia and episodes of V/D
Bicycle safety:
- Parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike’s center bar.
- Children should ride their bikes single file rather than side by side
- To decrease risk for injury when riding a bike at night, children should wear light colored clothing that has fluorescent material attached. This measure, aling with fluorescent material on the bike itself, makes bike riders more visible to motor vehicle drivers and other bike riders
- Bike riders should ride in the direction of the flow of traffic
Nutritional needs of a child with C.F
- Administer pancreatic enzymes within 30 minutes of meals and snacks to replace the enzymes lost with C.F
- A child who has C.F and develops steatorrhea might need to have their dosage of
pancreatic enzyme increased by their provider until the steatorrhea resolves
- The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration
- A child who has C.F is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child’s fat intake to 35% to 40% of total caloric intake
Findings in a child w/ Kawasaki disease: [Show Less]
