Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

Dyspnea

Heart rate

Blood pressure

Oxygen saturation

Respiratory rate

Oral intake

Lung sounds

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Assessment Finding	Improved	No change
Dyspnea		✅
Heart rate	✅
Blood pressure	✅
Oxygen saturation	✅
Respiratory rate	✅
Oral intake	✅
Lung sounds		✅

Rationale:

Improved:

Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.

Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.

No change:

Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.

Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

A. Pulmonary stenosis is one of the characteristic features of TOF, causing obstruction to blood flow to the lungs.
B. Overriding aorta is a defining feature of TOF, where the aorta is positioned over the ventricular septal defect, leading to mixing of oxygenated and deoxygenated blood.
C. Right ventricular hypertrophy occurs in TOF due to increased workload on the right ventricle caused by pulmonary stenosis.
D. Coarctation of the aorta is not part of Tetralogy of Fallot; it is a separate congenital defect.
E. A ventricular septal defect is the hole between the ventricles in TOF, leading to the mixing of oxygenated and deoxygenated blood.

A. Help the child accept the loss of control associated with hospitalization. B. Help the child accept pain that is connected with a treatment or procedure. C. Prepare the child before any unfamiliar treatment or procedure. D. Prepare the child for separation from parents during hospitalization by reviewing a video.

Correct Answer is C

Explanation

A. Rather than helping the child accept a loss of control, atraumatic care focuses on empowering the child and promoting a sense of control through participation in care and decision-making.

B. While pain management is crucial, the goal is not to have the child "accept" pain but to minimize it through interventions like distraction, pharmacologic pain relief, and comfort measures.

C. Preparing the child for unfamiliar treatments or procedures aligns with the principles of atraumatic care, which aim to reduce fear, anxiety, and physical and emotional distress. By offering developmentally appropriate explanations, the nurse helps the child feel more in control and reduces the traumatic impact of the experience.

D. Atraumatic care emphasizes maintaining parental involvement during hospitalization whenever possible. Preparing the child for separation does not align with atraumatic care principles, as separation is a source of stress that should be minimized.

View Question and Answer

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Exhibits The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","E"]

Explanation

Which intervention would the nurse include when providing atraumatic care?

Correct Answer is C

Explanation

A nurse is caring for a 6-year-old client who has nephrotic syndrome. Which of the following adverse effects of corticosteroids should the nurse recognize as having the potential to impact the child's psychosocial development? (Select All that Apply.).

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and had decided to move out of the house. Which of the following statements should the nurse make?

An acute care nurse is caring for a pediatric client diagnosed with diabetes mellitus who receives insulin injections. Which of the following actions by the nurse demonstrates atraumatic care?

A nurse is educating caregivers about dietary management for a child who has burn injuries. Which of the following recommendations should the nurse provide?

A nurse is receiving change of shift report on four children. Which of the following children should the nurse assess first?

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?

Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.