ATI PED Unit 3 Assessment

The correct answer is C: Place the client on his side.

Explanation: When a client is having a seizure, the nurse should place the client on their side to help maintain an open airway and reduce the risk of aspiration. This position allows any fluids (such as saliva or vomit) to drain from the mouth and prevents choking. It also helps prevent the client from aspirating on their own vomit or secretions, which could lead to further complications, such as aspiration pneumonia.

Why the Other Answers Are Incorrect:

A. Insert a tongue blade in the client's mouth.

Inserting a tongue blade or any object into the mouth during a seizure is dangerous. It can cause injury to the client’s mouth, teeth, or airway, and could result in the object being bitten or inhaled, leading to further complications. The best practice is to keep the area around the client clear and not put anything in their mouth.

B. Place the client back in bed.

It is not safe to attempt to move a client back into bed during a seizure. The priority should be ensuring the client is safe during the seizure (e.g., positioning them on their side and protecting their head). Moving the client could cause additional harm, such as falls or injury from the bed or surrounding furniture.

D. Hold the client's arms and legs from moving.

Trying to restrain the client's movements during a seizure is not recommended. Seizures are uncontrolled, and trying to stop or limit the movements could result in injury to both the client and the nurse. Instead, the nurse should allow the seizure to occur without interference and focus on ensuring the client is in a safe position (on their side) to prevent injury.

Summary: The most appropriate action when witnessing a client having a seizure is to place the client on their side. This position helps maintain an open airway and reduces the risk of aspiration. The nurse should not attempt to insert objects into the mouth, move the client back to bed, or restrain their movements during the seizure. These actions can cause further harm to the client. The nurse should also monitor the duration of the seizure and provide further assistance as necessary, such as calling for help or documenting the event.

The correct answer is B: Processed foods are acceptable, as long as they don't contain flour.

Explanation:

This statement indicates a misunderstanding about celiac disease and the risks associated with processed foods. Although flour is a major source of gluten, many processed foods may still contain hidden gluten from ingredients like malt, modified food starch, hydrolyzed vegetable protein, and soy sauce. Additionally, even products that do not list flour may be cross-contaminated if produced in facilities that also handle gluten-containing ingredients. For individuals with celiac disease, it is essential to choose certified gluten-free processed foods to prevent unintentional gluten exposure.

Why the Other Options Are Incorrect:

A. I need to check food labels for hidden sources of gluten, like barley and rye.

This is a correct statement. People with celiac disease must be diligent about reading labels because gluten can be present in unexpected ingredients, including barley, rye, malt, and triticale. Regularly checking food labels helps avoid accidental gluten ingestion.

C. My family should use separate serving utensils for gluten-free foods.

This is a correct statement. Cross-contamination is a significant concern for individuals with celiac disease. Sharing utensils, cooking surfaces, or food preparation tools between gluten and gluten-free foods can lead to gluten exposure, causing symptoms and intestinal damage.

D. I need to avoid foods like bread, pasta, and cereal.

This is a correct statement. Traditional bread, pasta, and cereal typically contain wheat or other gluten-containing grains. People with celiac disease must eliminate these items from their diet and seek gluten-free alternatives made from rice, corn, quinoa, or certified gluten-free oats.

Summary:

The statement that requires further teaching is "Processed foods are acceptable, as long as they don't contain flour." Many processed foods contain hidden gluten or are cross-contaminated. Patients with celiac disease must be careful to read food labels thoroughly and select certified gluten-free products to maintain a safe and gluten-free diet.

The correct answer is A: Pyloromyotomy

Explanation:

A. Pyloromyotomy: Pyloromyotomy is the most common and definitive surgical treatment for pyloric stenosis. Pyloric stenosis is a condition where the pyloric muscle, which connects the stomach to the small intestine, becomes hypertrophied (enlarged), causing a narrowing of the pyloric canal. This leads to an obstruction of food passing from the stomach to the duodenum (the first part of the small intestine). In pyloromyotomy, the surgeon makes an incision through the thickened pyloric muscle, which allows the passage of food from the stomach into the intestine. This procedure is typically performed laparoscopically (minimally invasive surgery), although it can also be done through an open incision in some cases. The surgery is highly effective, and the prognosis for recovery is excellent once the obstruction is relieved.

Why the Other Choices Are Incorrect:

B. Cheiloplasty: Cheiloplasty refers to the surgical repair of a cleft lip, a congenital condition where there is an opening or gap in the upper lip. This surgery is unrelated to pyloric stenosis, which involves a blockage at the pylorus, not the lip. The term cheiloplasty specifically addresses lip reconstruction, typically done in infants with cleft lip defects.

C. Appendectomy: An appendectomy is the removal of the appendix, often performed when the appendix becomes inflamed due to appendicitis. It is a completely different surgical intervention, not related to pyloric stenosis. The appendix is part of the digestive system but is not involved in the pathology of pyloric stenosis.

D. Gastroduodenostomy: A gastroduodenostomy is a procedure in which a new connection (anastomosis) is created between the stomach and the duodenum, typically used for conditions like stomach cancer, peptic ulcers, or gastric outlet obstruction. However, this is not the treatment for pyloric stenosis. Pyloric stenosis is managed by relieving the obstruction at the pylorus, and gastroduodenostomy is not indicated for this condition.

Summary: The surgical intervention for pyloric stenosis is pyloromyotomy. This procedure involves cutting the thickened pyloric muscle to relieve the blockage and allow food to pass through the stomach into the small intestine. It is the most effective and common treatment for pyloric stenosis. The other options, cheiloplasty, appendectomy, and gastroduodenostomy, are procedures for other conditions and are not used for pyloric stenosis.

The correct answer is B: Absolute neutrophil count (ANC)

Explanation:

The absolute neutrophil count (ANC) is the most accurate measure of a child’s infection-fighting capability, especially during chemotherapy. Neutrophils are a type of white blood cell (WBC) that play a critical role in the immune response, helping to fight infections by attacking bacteria, viruses, and other pathogens. Chemotherapy often causes bone marrow suppression, reducing the production of neutrophils, which increases the risk of infections.

An ANC below 1,500 cells/mm³ is called neutropenia, and a count below 500 cells/mm³ significantly increases the risk of serious infection. Monitoring ANC helps the healthcare team assess whether it is safe to administer chemotherapy or if treatment should be delayed to prevent life-threatening infections.

Why the Other Options Are Incorrect:

A. Red blood cell count (RBC)

This is incorrect because while chemotherapy can also suppress red blood cell production, which may lead to anemia, the RBC count does not directly measure the child’s ability to fight infections. RBCs are responsible for oxygen transport, but their levels do not indicate immune function.

C. Hemoglobin (Hgb)

This is incorrect because hemoglobin reflects the oxygen-carrying capacity of the blood. Although low hemoglobin may cause fatigue and pallor, it does not provide information about immune competence or infection risk.

D. Eosinophils

This is incorrect because eosinophils are a type of white blood cell primarily involved in allergic reactions and parasitic infections. They are not a significant indicator of overall immune function or infection risk in patients receiving chemotherapy. Monitoring neutrophils, not eosinophils, is the priority for assessing infection risk.

Summary:

The correct answer is "Absolute neutrophil count (ANC)." Monitoring ANC is essential when caring for children receiving chemotherapy because it directly reflects their infection-fighting capacity. A low ANC increases the risk of infections, which can be life-threatening in immunocompromised patients.

The correct answer is B: Bradycardia, high blood pressure, irregular respirations

Explanation:

Cushing's triad is a set of three primary signs that indicate increased intracranial pressure (ICP). This condition often occurs after brain trauma, surgery, or other neurological issues. The three classic findings of Cushing’s triad are:

Bradycardia (slow heart rate) – Increased pressure on the brainstem affects the vagus nerve, leading to a decreased heart rate.

Hypertension (high blood pressure) – There is a widened pulse pressure (a larger difference between systolic and diastolic pressures) as the body attempts to maintain blood flow to the brain.

Irregular respirations – Pressure on the brainstem affects respiratory centers, leading to abnormal breathing patterns, such as Cheyne-Stokes respirations or apnea.

These signs indicate brainstem compression, which is a neurological emergency requiring immediate intervention.

Why the Other Options Are Incorrect:

A. Bradycardia, hypotension, tachypnea

This is incorrect because hypotension (low blood pressure) is the opposite of what occurs with Cushing's triad. Increased ICP causes hypertension, not hypotension. Also, tachypnea (rapid breathing) is not typical of Cushing’s triad.

C. Increased temperature, tachycardia, tachypnea

This is incorrect because while increased temperature may occur with brain injury, tachycardia (fast heart rate) and tachypnea (rapid breathing) are not part of Cushing's triad. These findings are more consistent with systemic infection or fever-related responses.

D. Decreased temperature, bradycardia, bradypnea

This is incorrect because while bradycardia is part of Cushing’s triad, decreased temperature is not a characteristic finding. Bradypnea (slow breathing) does not capture the irregular nature of the breathing seen in this condition.

Summary:

The correct answer is B. Bradycardia, high blood pressure, irregular respirations. These findings indicate Cushing's triad, a life-threatening condition caused by increased intracranial pressure, and require urgent medical intervention to prevent further brain damage or death.

The correct answer is D: The child will need to follow a gluten-free diet for the rest of their life.

Explanation:

D. The child will need to follow a gluten-free diet for the rest of their life:

Celiac disease is a lifelong autoimmune disorder that requires strict avoidance of gluten, a protein found in wheat, barley, and rye. If a child with celiac disease consumes gluten, it can trigger an immune response that damages the small intestine, leading to malabsorption of nutrients and other long-term complications. Therefore, the most important information for parents is that their child will need to follow a gluten-free diet for the rest of their life to manage the condition and prevent further damage.

WHY THE OTHER OPTIONS ARE WRONG 

A. The child will only need to follow a gluten-free diet until they reach adolescence:

This statement is incorrect. Celiac disease is a chronic condition that requires lifelong management. There is no age at which individuals with celiac disease can safely reintroduce gluten into their diet. A gluten-free diet is essential for maintaining health and preventing complications at any age.

B. The child can eat gluten as long as they take enzyme supplements:

This statement is also incorrect. Currently, there are no enzyme supplements that can replace the need for a strict gluten-free diet in individuals with celiac disease. The only effective treatment for managing celiac disease is complete elimination of gluten from the diet. Enzyme supplements may help with other digestive issues, but they cannot protect the body from the damage caused by gluten in celiac disease.

C. The child can occasionally consume small amounts of gluten without any consequences:

This is not true. Even small amounts of gluten can trigger an immune response in individuals with celiac disease, leading to intestinal damage and other health issues. There is no safe threshold for gluten consumption in people with celiac disease, so a strict gluten-free diet is necessary at all times.

Summary:

The most important information to include in the dietary teaching plan is that the child will need to follow a gluten-free diet for the rest of their life. This is the cornerstone of managing celiac disease and preventing long-term complications. Gluten consumption, even in small amounts, is harmful, and there are no enzyme supplements or age restrictions that would allow for reintroducing gluten into the diet.

The correct answer is B: Brudzinski's sign

Explanation:

B. Brudzinski's sign:

What it is: Brudzinski's sign is a clinical sign that suggests the presence of meningitis or meningeal irritation. It is tested by passively flexing the neck of the patient. In a positive Brudzinski’s sign, the flexion of the neck leads to an involuntary flexion of the hips and knees. This occurs due to the irritation of the meninges surrounding the brain and spinal cord, which causes pain when the neck is flexed.

Why it is correct: In this scenario, the nurse observes involuntary flexion of the client's legs upon passive neck flexion, which is a hallmark of Brudzinski's sign. This indicates meningeal irritation, often caused by conditions like meningitis.

Why the Other Options Are Incorrect

A. Nuchal rigidity:

What it is: Nuchal rigidity refers to the stiffness or resistance when trying to flex the neck forward. It is a clinical sign of meningeal irritation and is often observed in cases of meningitis. However, nuchal rigidity is a physical finding related to neck stiffness rather than an involuntary leg response. It does not involve flexion of the legs.

Why it is incorrect: Although nuchal rigidity is commonly seen in meningitis, it does not cause the involuntary leg flexion described in this scenario. Nuchal rigidity alone is not a complete or sufficient indicator of meningitis in the context of the provided symptoms

C. Bradykinesia:

What it is: Bradykinesia is a term used to describe slowness of movement and is a common symptom of Parkinson’s disease. It involves difficulty initiating or controlling movements, typically seen in neurological disorders like Parkinson's disease.

Why it is incorrect: Bradykinesia does not involve neck flexion or the flexion of the legs, and it is unrelated to meningitis or meningeal irritation. The symptoms described do not fit the presentation of bradykinesia, as this condition does not include the specific physical signs of meningeal irritation like the flexion of the legs upon neck flexion.

D. Kernig's sign:

What it is: Kernig's sign is another clinical test used to evaluate meningeal irritation. It is tested by flexing the patient’s hip and knee at 90 degrees, then attempting to straighten the leg. A positive Kernig's sign occurs when the patient experiences pain or resistance during the leg extension, which indicates meningeal irritation

Why it is incorrect: While Kernig's sign is related to meningeal irritation like Brudzinski’s sign, it specifically involves resistance to leg extension when the hip is flexed. This is not the same as Brudzinski’s sign, which involves flexion of the legs when the neck is flexed. The nurse in this case described involuntary leg flexion upon neck flexion, which aligns with Brudzinski’s sign, not Kernig’s.

Summary: Brudzinski’s sign is the correct answer because it specifically involves the involuntary flexion of the legs when the neck is flexed, a common finding in patients with meningitis or other causes of meningeal irritation. While nuchal rigidity, Kernig’s sign, and bradykinesia are related to neurological or meningeal issues, they do not present with the same leg response described in this scenario.

The correct answer is B. 3-6 months

Explanation:

B. 3-6 months:

Cleft lip repair, or cheiloplasty, is typically performed between 3 to 6 months of age. This timing is ideal for ensuring that the child has adequate growth and healing potential while minimizing the risk of complications. Repairing the cleft lip at this age helps to improve feeding, speech development, and reduces the risk of social and psychological issues that may arise from a visible deformity.

WHY THE OTHER OPTIONS ARE WRONG:

A. 2-3 months:

While some children may undergo cleft lip repair slightly earlier than 3 months, the ideal window for surgery is generally closer to 3-6 months. Performing the surgery at 2-3 months may still be too early, as the child may not have reached the necessary growth milestones to ensure successful healing.

C. 6-12 months:

Surgery for cleft lip repair is not typically performed at this age. This age range is usually more appropriate for cleft palate repair (palatoplasty), which generally occurs between 6 and 12 months of age. Cleft lip repair is done earlier, typically between 3 and 6 months.

D. 1-2 years:

Performing cleft lip repair at 1-2 years is considered too late. Early surgical intervention (3-6 months) provides the best results in terms of feeding, speech development, and psychosocial adaptation.

Summary:

Cleft lip repair typically occurs between 3 to 6 months of age. This timing ensures the best outcomes in terms of feeding, speech development, and social adaptation. The cleft palate repair usually takes place between 6 to 12 months, and speech assessments are typically done at 18 months and 3 years.

The correct answer is C: Increased sleepiness

Explanation:

Increased sleepiness (or lethargy) is a key sign of increased intracranial pressure (ICP) in infants. When pressure within the skull rises due to trauma, it can compress brain structures, reducing arousal and causing decreased consciousness. This symptom can indicate cerebral edema, bleeding, or brain injury. Irritability, poor feeding, and bulging fontanels are also common signs of increased ICP in infants.

Why the Other Options Are Incorrect:

A. Brisk pupillary reaction to light

This is incorrect because a brisk (rapid and equal) pupillary reaction to light is a normal finding, indicating healthy brainstem function. With increased ICP, the nurse would expect sluggish or unequal pupil responses, or dilated, fixed pupils in severe cases.

B. Depressed fontanels

This is incorrect because depressed fontanels indicate dehydration or hypovolemia, not increased ICP. With increased ICP, the fontanels would typically be bulging or tense due to elevated pressure within the skull.

D. Tachycardia

This is incorrect because increased ICP typically causes bradycardia (slow heart rate) rather than tachycardia (fast heart rate). This occurs due to pressure on the brainstem, which regulates vital functions. Cushing’s triad—a late sign of severe ICP—includes bradycardia, hypertension, and irregular respirations.

Summary:

The correct answer is "Increased sleepiness." This is a significant indicator of increased intracranial pressure in infants. Prompt assessment and intervention are crucial to prevent brain damage and other complications. Monitoring for bulging fontanels, vomiting, altered consciousness, and pupil changes is essential in infants with head trauma.