ATI CRITICAL THINKING EXAM

NCLEX questions cognitive analysis 81 to 150 5.0 (1 review) Students also studied Terms in this set (106) Science MedicinePaediatrics Save TRansition - Respiration NCLEX Que...107 terms Maria_Ho-Fung Preview 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview

ATI CRITICAL THINKING EXAM

Teacher 40 terms diana_peralta898 Preview NCLEX 75 terms pnn The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply.

Rationale:

The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing glovesand a gown) reduce the nosocomial transmission of RSV.Recalling the mode of transmission of RSV will assist you with determining that the infant needs to be placed in a private room or in a room with another child with RSV and that contact precautions need to be maintained. Recalling the reasons to maintain a patent airway (edema and the accumulation of mucus obstruct the bronchioles) will assist you with determining that the infant needs to be observed closely, that the infant's head should be elevated, and that the infant should receive cool, humidified oxygen.The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, a high fever, and a sore throat.The nurse reviews the results of a tuberculin skin test performed on a 3-year-old child. The results indicate an area of induration that measures 10 mm. How should the nurse interpret this result?An induration that measures 10 mm or more is considered to be a positive result for children who are younger than 4 years old and for those with chronic illness or with a high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for those in the highest-risk groups.

The nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis.Which specific sign/symptom of aortic stenosis should the nurse anticipate?The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines if the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.The nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF?The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with HF, but it is also not an early sign.The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform?The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee- chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation, and it usually occurs with exertional activities.The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which finding is associated with the diagnosis of glomerulonephritis?Gross hematuria resulting in dark, smoky, cola-colored or red-brown urine is a classic symptom of glomerulonephritis, and hypertension is also common. A mid- to high urinary specific gravity is associated with glomerulonephritis. BUN levels may be elevated.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply.Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor.The urine volume is decreased, and the urine is dark and frothy in appearance.The child with this condition gains weight.The nurse is planning care for a child with hemolytic- uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which intervention in the care of the child?HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be on fluid restrictions. Pain is not associated with HUS, and potassium would be restricted rather than encouraged if the child was anuric.Peritoneal dialysis does not require an AV fistula (only hemodialysis does).The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 3, and 4 are not characteristically noted with this condition.The nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures.Which action would best assist in determining the causes of the seizure?Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5 years old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema.Some medications could cause seizures. Specific gravity would not be a reliable test because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.A child has a basilar skull fracture. Which health care provider's prescription should the nurse question?Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture.Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake and output. An IV line is maintained to administer fluids or medications, if necessary.Which laboratory result would verify the diagnosis of bacterial meningitis?A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.The nurse is assisting to develop a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.During a seizure, the child is placed on his or her side in a lateral position. This type of positioning will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for the observation and timing of the seizure.The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, which is a priority intervention?A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristic of this type of posturing?Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.The nurse, reinforcing home care instructions, prepares a list for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.The nurse is assigned to care for a child after a spinal fusion for the treatment of scoliosis. The child complains of abdominal discomfort and begins to have episodes of vomiting. On data collection, the nurse notes abdominal distention. Which action should the nurse take?A complication after the surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents that result from the lengthening of the child's body.It results in a syndrome of emesis and abdominal distention that is similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting among children with body casts or among those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Therefore, the remaining options are incorrect A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off and leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous and beefy red in color. Option 2 is associated with poliomyelitis.Abdominal pain and flaccid paralysis. Options 3 and 4 are characteristics of diphtheria. Dense pseudoformation membrane in the throat.Foul-smelling and mucopurulent nasal drainage Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.AIDS is a disorder that is caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Both cellular and humoral immunity are compromised. The horizontal transmission of HIV occurs through intimate sexual contact or parenteral exposure to blood or body fluids that contain visible blood. Vertical (perinatal) transmission occurs when an HIV-infected pregnant woman passes the infection to her infant. Home care instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level, and oral lesions and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with their tabs, and disposed of in a tightly covered plastic- lined container. Any body fluid spills are cleaned with a bleach solution made up

of a 10:1 ratio of water to bleach.