ATI RN Concept-Based Assessment Study Guide

ATI RN Concept-Based Assessment Study Guide The child with Down syndrome should be evaluated for which condition before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield spots) - ANSWER-C. Atlantoaxial instability - Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiologic examination should be done. Child with Down Syndrome delayed development - ANSWER--nurse should ensure the child is enrolled in an early stimulation program which provides PHYSICAL THERAPY to develop motor skills. manifestations of increased ICP - ANSWER--decreased LOC -vomiting (often projectile) -rising bp -increasing pulse pressure -bradycardia -papilledema -fixed and dilating pupils -posturing (decorticate and decerebrate) -HTN -Cheyne-stokes respirations -wide pulse pressure manifestations of acute glaucoma - ANSWER--headache -eye pain -rapid onset of elevated IOP -vision alterations -severe pain -photophobia manifestations of DKA - ANSWER-dehydration, eyeballs soft and sunken eyes, ab pain, anorexia, KUSSMAUL RESPIRATIONS, fruity breath What nursing interventions should take priority on a client with placenta previa at 36 weeks gestation? - ANSWER--initiate large-bore IV access Education for preventing child-hood obesity - ANSWER--avoid using foods as a reward for good behavior -have healthy foods like fruits and veggies available for snacking -limit television watching to 2hr or less each day -avoid offering juice drinks (high sugar content) positive symptoms of schizophrenia - ANSWER-Delusions of reference, delusions of persecution, delusions of grandeur, thought broadcasting, though insertion -magical thinking -auditory hallucinations -clang association disorganized thought, disorganized behavior, catatonia negative symptoms of schizophrenia - ANSWER--disturbance of affect -blunting (severe reduction in the intensity of affect expression) -flat affect -inappropriate affect (might laugh hysterically while describing someones death) -emotional ambivalence nursing priority for patient with WILMs Tumor - ANSWER--avoid palpation of abdomen to avoid tumor rupture What is Wilm's tumor? - ANSWER-Renal tumor of embryonal origin that is most commonly seen in children 2-5yrs Assoc w/ Beckwith-Wiedemann syndrome (hemihypertrophy, macroglossia, visceromegaly), NF, and WAGR syndrome (Wilms' Aniridia, Genitourinary abnormalities, mental retardation) Nursing intervention for child born at 33wks and is 2 days old - ANSWER--position newborn SIDE-LYING or Prone while in nursery. -bathe child in PLAIN WATER ONLY -initiate skin-to-skin contact regardless of age or weight of newborn -lights should be dimmed during the night and at intervals during the day intimate partner violence teaching - ANSWER--nurses priority is to provide safety and develop a safety plan. Teaching for minimizing behavioral problems with client who has Alzheimer's disease (AD) - ANSWER--briefly leave the room when client becomes agitated -use a soft, calm tone of voice -avoid crowds of people when taking client on outings.