ATI RN Concept-Based Assessment Level III Study Guide

e 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 participatingin 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-- positionnewborn 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 anddevelop 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. manifestations of prenatal complications - ANSWER--swelling of finders, face, and sacral area (these are hypertensive conditions like PREECLAMPSIA) PYROSIS - ANSWER-heartburn; burning sensation in upper abdomen due to reflux of gastric acid leukorrhea - ANSWER-a profuse, whitish mucus discharge from the uterus and vagina