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Ati rn comprehensive predictor 2023 proctored exam
Total Questions : 163
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Child is accompanied by their parent. Parent reports that their child is experiencing stomach pain and occasional vomiting. Parent states the child eats well, but sometimes has severe pain that causes them to "draw their knees to their chest" and scream, but then returns to being themself. Parent noted blood and mucus in the child's bowel movement today.
1310:
Child is alert and responsive to verbal stimuli. Pain rated as 5 on the Facial expression, Leg movement, Activity, Cry, Consolability (FLACC) scale. Lung sounds clear anterior and posterior. Respirations even, nonlabored. Heart rate regular. Abdomen. distended with hypoactive bowel sounds x 4 quadrants and tenderness with light palpation noted in right upper quadrant. Small, oblong, palpable mass noted in upper right quadrant.
1315:
Child vomited approximately 50 Ml light-colored emesis.
1320:
Temperature 37.4° C (99.3° F)
Heart rate 110/min
Respiratory rate 26/min
Blood pressure 95/56 mm Hg
A nurse in an acute care facility is caring for a toddler.
For each assessment finding below, click to specify if the assessment finding is consistent with Crohn’s disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.
Explanation
• Pain rating: The child’s history describes sudden, severe abdominal pain causing the child to draw their knees to their chest, with periods of relief between episodes. This episodic, colicky pain is classic for intussusception, as the bowel telescopes and intermittently obstructs intestinal flow.
• Vomiting: The child vomited approximately 50 mL of light-colored emesis, consistent with the obstruction caused by intussusception. Vomiting can also occur in appendicitis due to peritoneal irritation, particularly if inflammation is in the right upper quadrant.
• Temperature: The child has a mild fever of 37.4° C (99.3° F). This low-grade fever can indicate inflammation of the appendix, making appendicitis a consideration. Intussusception usually does not present with fever unless there is ischemia or infection, which is not indicated.
• Stool: The parent reports blood and mucus in the stool, which is classic “currant jelly” stool seen in intussusception. Crohn’s disease may also present with blood and mucus due to chronic bowel inflammation, but the sudden onset and combination with severe colicky pain point more strongly toward intussusception.
• Abdominal findings: On assessment, the child’s abdomen is distended with hypoactive bowel sounds and tenderness in the right upper quadrant, and a small, oblong palpable mass is noted in the same area. These findings are highly specific for intussusception, representing the telescoped segment of bowel that can be palpated as a sausage-shaped mass.
0800:
Client transported to emergency department by emergency medical services (EMS). Client found in a bathroom at a bar unresponsive and without a pulse. Report by EMS is that there was a needle in the client's left antecubital space. Naloxone was administered at the scene. EMS relayed that someone saw the client have one beer and then go to the bathroom.
Client drowsy, arouses to noxious stimuli, but falls back asleep quickly.
Eyes: Pupils reactive, miotic
Heart: Normal rate and rhythm
Lungs: Equal bilateral, clear to auscultation
Abdomen: Decreased bowel sounds
Skin: Marks in left antecubital space
Review of medical record 2 weeks prior:
Discharge note: At 0600, client transported to the emergency department by emergency medical services (EMS). Client was found in the park by runners, who then contacted EMS. Client presented with manifestations of sedation, miosis, hypokinesis, and mood alteration. Supportive care provided. At 1000, client reported stating, "I am going to throw up. I've never used this drug before." Assessment revealed mydriasis, hyperreflexia, diaphoresis, piloerection. Supportive care provided. Medications included buprenorphine/naloxone taper x 4 days. Client stabilized and discharged back to shelter after completing the 4- day buprenorphine/naloxone taper.
0800:
Temperature 37.2° C (99° F)
Heart rate 60/min
Respiratory rate 10/min
Blood pressure 98/64 mm Hg
Two weeks ago, 0600: \
Temperature 36.7° C (98.2° F)
Heart rate 62/min
Respiratory rate 14/min
Blood pressure 110/66 mm Hg
1000:
Temperature 37.4° C (99.4° F)
Heart rate 110/min
Respiratory rate 18/min
Blood pressure 148/86 mm Hg
Answer by using the lists of options.
The client likely experienced
Explanation
Rationale for correct choices
• opioid intoxication: The client was found unresponsive and pulseless with a needle present, strongly suggesting opioid use. Clinical findings of decreased level of consciousness, respiratory depression, hypotension, and response to naloxone align with opioid intoxication. Miotic pupils and decreased bowel sounds further support opioid effects on the central nervous system.
• pupil characteristics: The client’s pupils are miotic, which is a classic hallmark of opioid intoxication. Opioids stimulate parasympathetic pathways leading to pinpoint pupils, especially when combined with respiratory depression. Pupillary changes directly correlate with opioid receptor activation.
Rationale for incorrect choices
• alcohol withdrawal: Alcohol withdrawal typically presents with tremors, agitation, tachycardia, hypertension, diaphoresis, and possibly seizures. The client is instead bradycardic, hypotensive, and profoundly sedated. There is no history of alcohol dependence or recent cessation to support withdrawal.
• opioid withdrawal: Opioid withdrawal is characterized by mydriasis, diarrhea, vomiting, piloerection, tachycardia, and hypertension. The client shows opposite findings, including miosis, decreased respirations, and sedation. Naloxone administration implies overdose reversal rather than withdrawal management. Withdrawal would not cause respiratory depression.
• alcohol intoxication: Alcohol intoxication can cause CNS depression, but it does not produce pinpoint pupils or respond to naloxone. The reported intake of one beer is insufficient to explain unresponsiveness and apnea. Injection marks and prior opioid-related admissions further reduce the likelihood of alcohol as the primary cause. Pupillary findings are inconsistent with alcohol intoxication.
• breath sounds: Breath sounds are clear and equal bilaterally, which does not directly identify the cause of the condition. While respiratory rate is decreased, auscultation findings alone do not distinguish opioid intoxication from other causes. Breath sounds provide supportive but nonspecific information.
• amount of alcohol consumed: The reported consumption of one beer does not explain the severity of symptoms observed. Alcohol quantity is unreliable due to potential underreporting and does not correlate with the physical findings. The presence of injection marks and naloxone response outweigh the quantity of alcohol consumed.
• current temperature: The client’s temperature is within normal limits and does not contribute to identifying the cause. Fever or hypothermia might suggest infection or environmental exposure, which are not primary concerns here. Temperature changes are not characteristic markers of opioid intoxication.
1100:
The child's guardians report facial edema that is more prominent around the eyes, which decreases by the end of the day. The child also has a poor appetite.
1130:
The child is irritable and appears very tired. The child has difficulty breathing and has an enlarged abdomen. There are white lines on the fingernails that are parallel to the fingernail bed and skin is lighter than expected.
1100:
Temperature 37.3° C (99.1° F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 100/50 mm Hg
Oxygen saturation 95% on room air
1130:
Temperature 37° C (98.6° F)
Heart rate 102/min
Respiratory rate 22/min
Blood pressure 102/48 mm Hg
Oxygen saturation 96% on room air
1130:
Color: dark-colored (amber yellow)
Encourage a low-sodium diet.
Urine specific gravity
Appearance foamy (clear)
Protein 24 mg/dL (0 to 8 mg/dL)
Cast: Hyaline casts (none)
RBCS 6 (less than 2)
Specific gravity 2.066 (1.001 to 1.025)
Chemistry Panel:
Albumin 1.4 g/dL (4 to 5.9 g/dL)
Cholesterol 465 mg/dL (120 to 200 mg/dL)
Sodium 132 mEq/L (136 to 145 mEq/L)
Calcium 5.18 mg/dL (8.8 to 10.8 mg/dL)
Hgb 14.5 g/dL (10 to 13.5 g/dL)
Hct 42% (32% to 44%)
Platelets 600,000/mm3 (150,000 to 400,000/mm3)
Erythrocyte sedimentation rate (ESR) 22 mm/hr (up to 10 mm/hr)
A nurse is caring for a school-age child in the pediatric unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for correct choices
• Nephrotic syndrome: The child presents with periorbital edema, hypoalbuminemia, hyperlipidemia, proteinuria, and foamy dark urine, classic signs of nephrotic syndrome. The edema fluctuates during the day and laboratory values confirm protein loss. The condition is primarily due to increased glomerular permeability rather than infection or chronic renal disease.
• Encourage a low-sodium diet: A low-sodium diet helps reduce fluid retention and edema associated with hypoalbuminemia. Managing sodium intake supports blood pressure stability and decreases further renal strain. Dietary management complements pharmacologic treatment and promotes comfort by decreasing swelling.
• Administer oral corticosteroids: Corticosteroids are the first-line treatment for nephrotic syndrome, reducing proteinuria and inflammation. Timely administration can induce remission and prevent progression. Steroid therapy also helps normalize serum albumin levels, contributing to improved oncotic pressure and reduced edema.
• Abdominal girth: Monitoring abdominal girth allows early detection of ascites and worsening edema. Progressive increase in girth indicates fluid retention and guides fluid management. This parameter provides a visual and measurable indicator of the child’s response to therapy.
• Urine specific gravity: Urine specific gravity tracks protein loss and hydration status. Elevated values indicate concentrated urine due to proteinuria, which is a hallmark of nephrotic syndrome. Monitoring changes helps assess treatment efficacy and disease progression.
Rationale for incorrect choices
• Acute glomerulonephritis: Typically presents with hematuria, hypertension, and mild proteinuria, often after a recent infection. This child has massive proteinuria and hyperlipidemia, which aligns more with nephrotic syndrome. The edema pattern and labs do not support post-infectious glomerulonephritis.
• Chronic kidney disease: CKD develops over months to years with progressive renal insufficiency, azotemia, and electrolyte imbalances. The child has normal kidney function aside from proteinuria and edema, indicating acute onset rather than chronic progression.
• Hemolytic uremic syndrome: HUS often presents with microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury following diarrhea. Although the child has proteinuria and edema, hemoglobin and platelet counts do not indicate HUS. Lab pattern and history do not support this diagnosis.
• Administer IV antibiotics: There is no evidence of bacterial infection; labs and clinical presentation point to proteinuria from nephrotic syndrome rather than infection. Antibiotics would not address the underlying glomerular pathology.
• Initiate peritoneal dialysis: Renal function is not severely impaired; serum creatinine is not reported elevated. Dialysis is unnecessary in uncomplicated nephrotic syndrome. Conservative management with diet and corticosteroids is appropriate.
• Initiate contact precautions: No infectious etiology is present. Contact precautions are not indicated. The condition is glomerular in origin, not transmissible.
• Abnormal HbA1c: Blood glucose or HbA1c is not relevant; the child does not have diabetes. This parameter does not assess nephrotic syndrome progression.
• Bilirubin: There is no evidence of hemolysis or liver dysfunction; bilirubin is not a relevant parameter. Monitoring bilirubin does not reflect nephrotic syndrome severity.
• Head circumference: Head circumference is not relevant in school-age children for assessing edema or renal disease. Changes in girth relate more to abdominal fluid retention than cranial growth at this age.
0800:
Guardian states child was awake most of the night complaining of pain, currently asleep. Heart rate regular without murmur. Respirations easy, shallow. Breath sounds clear throughout. Abdomen soft, tender in incisional area upon palpation. Absent bowel sounds. Right lower quadrant abdominal dressing dry and intact.
1200:
Child rates abdominal pain as 6 on the FACES pain rating scale. Alert and irritable, cooperates with coaxing/playing. Child refuses use of incentive spirometer. Heart rate regular without murmur. Respirations easy, shallow. Breath sounds clear throughout. Abdomen soft, more tender upon palpation as compared to 0800. Absent bowel sounds. Right lower quadrant abdominal dressing dry and intact.
1245:
Child rates abdominal pain as 4 on the FACES pain rating scale.
0800:
Temperature 37° C (98.6° F) temporal
Heart rate 118/min
Respiratory rate 20/min
Blood pressure 92/52 mm Hg
Weight 13.6 kg (30 lb)
1200:
Temperature 37.2° C (98.9° F) temporal
Heart rate 126/min
Respiratory rate 22/min
1600:
Temperature 37.7° C (99.9° F) temporal
Heart rate 124/min
Respiratory rate 24/min
Acetaminophen 120 mg rectally every 4 hr as needed for temperature greater than or equal to 38.5° C (101.3° F)
Morphine sulfate 1 mg IV every 3 hr as needed for pain
1215:
Morphine sulfate 1 mg IV
A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.
Complete the following sentence by using the lists of options.
The child is at risk for developing
Explanation
Rationale for correct choices
• Pneumonia: The child is at risk for postoperative pneumonia due to shallow breathing and refusal to use the incentive spirometer. Postoperative pain can limit deep breathing, decreasing alveolar expansion and promoting secretion retention. This immobility of airways increases the likelihood of atelectasis, which can progress to pneumonia if preventive measures are not implemented.
• Shallow breathing: Shallow respirations reduce tidal volume and limit lung expansion, contributing to alveolar collapse and secretion accumulation. This is a common postoperative risk, particularly in children reluctant to take deep breaths due to abdominal pain. Monitoring and encouraging deep breathing can help prevent pulmonary complications.
• Lack of incentive spirometer use: Refusal to use the incentive spirometer reduces lung expansion, promoting atelectasis and increasing risk for infection. Incentive spirometry is essential to prevent postoperative pulmonary complications.
Rationale for incorrect choices
• Postoperative ileus: Absent bowel sounds are expected in the immediate postoperative period and are not abnormal within the first several hours after abdominal surgery. The child’s abdominal tenderness and soft abdomen are consistent with normal post-surgical recovery. Ileus becomes a concern if bowel sounds remain absent beyond 24–48 hours or if the child develops vomiting or abdominal distention.
• Peritonitis: The child shows no signs of systemic infection, rebound tenderness, or rigid abdomen. The incision is dry and intact, and vital signs are stable with only mild temperature elevation. Peritonitis would present with diffuse abdominal pain, guarding, and often fever, none of which are present.
• Breath sounds: Breath sounds are clear throughout, indicating no active pneumonia at this time. While lung expansion is limited, auscultation does not show crackles, wheezing, or other abnormal findings. Breath sounds alone do not indicate risk; shallow breathing and incentive spirometer non-use are more predictive of pulmonary complications.
• Absent bowel sounds: In the immediate postoperative period, bowel sounds may be decreased or absent for several hours due to anesthesia and surgical manipulation. This finding should not be interpreted as abnormal at this stage.
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?
A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
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