ATI- Pre Assessment Nursing Care of Children QUESTIONS AND ANSWERS.docx

  Drawing, painting, riding a tricycle -Correct Answers: preschoolers Banging large block -Correct Answers: 9 - 12 months Team sports -Correct Answers: school-aged Watching black-and-white mobiles -Correct Answers: Birth to 3 months Playing peek-a-boo -Correct Answers: 6 to 9 months Holding a soft rattle -Correct Answers: 3 to 6 months Loud, harsh murmur; Mild heart failure; Possible enlarged right atrium; Increased oxygen saturations in the right atrium; Asymptomatic (possibly). -Correct Answers: Atrial septal defect (ASD) Increased blood pressure and oxygen saturation in the upper extremities compared to the lower extremities; Nosebleeds; Headaches, vertigo, leg pain, weak or absent lower extremity pulses (indicate decreased cardiac output). -Correct Answers: Coarctation of the aorta Murmur (machine-hum); Wide pulse pressure; Bounding pulses; Asymptomatic (possibly) -Correct Answers: Patent ductus arteriosus (PDA) Systolic ejection murmur; Right ventricular enlargement; Exercise intolerance; Cyanosis with severe narrowing. -Correct Answers: Pulmonary stenosis Loud, harsh murmur that is not usually audible until pulmonary pressures drop at about 4 to 8 weeks of age; Heart failure; Failure to thrive; Small, possibly asymptomatic defects. -Correct Answers: Ventricular septal defect (VSD) Murmur; Cyanosis, severe dyspnea, clubbing of the fingers, hypercyanotic spells, and acidosis; Polycythemia, clot formation; Frequently sits in a squatting position (decreases venous return); Failure to thrive and growth retardation -Correct Answers: Tetralogy of Fallot May have difficulty accepting death because they are discovering who they are, establishing an identity, and dealing with issues of puberty. -Correct Answers: Adolescents Experience fear of the disease process, the death process, the unknown, and loss of control -Correct Answers: School-age children Have egocentric thinking that prevents them from understanding death. -Correct Answers: Toddlers View dying as temporary because they have no concept of time and because the dead person may still have attributes of the living (sleeping, eating, breathing). -Correct Answers: Preschool A nurse is caring for a 6-month-old infant following surgery. Which of the following should the nurse use to measure pain in this client? a. FLACC pain scale. b. There is no special pain scale for infants. c. Wong-Baker faces pain rating scale. d. Oucher numeric scale. -Correct Answers: a. FLACC pain scale. A nurse is caring for an infant following a cleft lip and palate repair. Which of the following actions should the nurse take in the post-operative period? Select one: a. Encourage the use of a pacifier. b. Assess incision using tongue blade. c. Provide hard toys. d. Administer analgesics. -Correct Answers: d. Administer analgesics. The nurse should keep the infant pain-free to decrease crying and stress on the repair. A nurse is caring for a child with a closed head injury. Which of the following interventions should the nurse institute to decrease intracranial pressure? Select all that apply. Select one or more: a. Instruct to avoid coughing and blowing nose. b. Keep the head of the bed flat. c. Provide a calm, restful environment. d. Avoid extreme flexion, extension or rotation of the head. e. Keep the body in alignment. -Correct Answers: Avoid extreme flexion, extension or rotation of the head., Keep the body in alignment., Instruct to avoid coughing and blowing nose., Provide a calm, restful environment. Which of the following is the priority intervention a nurse should take when caring for a child who just experienced a febrile seizure? Select one: a. Check for injuries. b. Reorient to the environment. c. Keep in a side-lying position. d. Take vital signs. -Correct Answers: c. Keep in a side-lying position. The greatest risk for the child is aspiration. Therefore, the priority intervention during the postictal phase is to keep the child in a side-lying position so secretions can drain from the mouth. The other interventions are important, but they are not the priority at this time. A nurse is providing discharge education to the parents of a child experiencing acute diarrhea secondary to gastroenteritis. Which of the following should the nurse include? Select one: a. Provide fruit juices throughout the day. b. Provide chicken or beef broth throughout the day. c. Use prepared oral replacement solutions (ORS). d. Use the BRAT (bananas, rice, applesauce and toast) diet. -Correct Answers: c. Use prepared oral replacement solutions (ORS). A school nurse is providing education to a child's mother regarding head lice. Which of the following should the nurse include? Select one: a. Lice and nits do not survive away from a host. b. Your child cannot get lice if their hair is kept clean. c. Children should be instructed to not share hats or combs. d. It is very easy to catch lice as they can jump from head to head. -Correct Answers: c. Children should be instructed to not share hats or combs. Lice are transmitted by contact such as via personal items like hats and combs. A nurse is caring for a 6-month-old client who has sudden abdominal pain, vomiting, distended abdomen and red current jelly-like stools. The nurse should know that these are signs for which of the following? Select one: a. Intussusception. b. Appendicitis. c. Pyloric stenosis. d. Hernia. -Correct Answers: a. Intussusception. Intussusception is the telescoping of the intestine over itself. This usually occurs in infants and young children up to 5 years of age, but it is most common between 5 and 9 months of age. Manifestations include: • Normal comfort interrupted by periods of sudden and acute pain • Palpable, sausage-shaped mass in the right upper quadrant of the abdomen and/or a tender, distended abdomen • Stools that are mixed with blood and mucus that resemble the consistency of red currant jelly A nurse is caring for an adolescent client diagnosed with mononucleosis. Which of the following statements by the client's parent indicates a need for further education? Select one: a. "I will prevent him from participating in strenuous activities." b. "I will encourage him to get plenty of rest." c. "I will encourage him to drink plenty of liquids." d. I will give him aspirin as needed for fever and discomfort." -Correct Answers: d. I will give him aspirin as needed for fever and discomfort." A nurse is assessing the physical development of a 3-month-old infant. Which if the following findings would indicate that the infant may be developmentally delayed? Select one: a. Does not attempt to raise head when placed on stomach. CorrectCorrect. By 3 months of age the infant should be raising the head and shoulders off of the mattress. b. Rolls from back to front. c. Does not attempt to sit up without support. d. Does not pick up objects with fingers. -Correct Answers: a. Does not attempt to raise head when placed on stomach. By 3 months of age the infant should be raising the head and shoulders off of the mattress. A nurse is providing dietary education to the mother of an infant. What recommendations regarding the introduction of solid foods to the infant's diet should the nurse make? Select all that apply. Select one or more: a. New foods should be introduced one at a time over a 5- to 7-day period to observe for signs of allergies or intolerance. b. Milk, eggs, wheat, citrus, peanut butter and honey can be given after 6 months of age. c. Vegetables or fruits are first started between 6 and 8 months of age. After both have been introduced, meats can be added. d. Iron-fortified rice cereal should be offered first. e. Solids can be introduced between 4 and 6 months of age. -Correct Answers: a, c, d, e - Solids can be introduced between 4 and 6 months of age., Iron-fortified rice cereal should be offered first., New foods should be introduced one at a time over a 5- to 7-day period to observe for signs of allergies or intolerance., Vegetables or fruits are first started between 6 and 8 months of age. After both have been introduced, meats can be added. A nurse is providing developmental education to the mother of a 2-year-old child. What information regarding temper tantrums should the nurse include? Select one: a. This indicates a type of learning disability. b. A psychological consult is needed. c. Give the child whatever they want to prevent tantrums. d. This is a child's way of trying to gain control and power. -Correct Answers: d. This is a child's way of trying to gain control and power. Temper tantrums are common during the toddler years because at this age the child becomes easily frustrated with restrictions on independence. Providing consistent, age-appropriate expectations helps toddlers to work through frustration. What manifestations should the nurse anticipate for the client with rheumatic fever? Select all that apply. Select one or more: a. CNS involvement (chorea) including involuntary, purposeless muscle movements b. Nontender, subcutaneous nodules over bony prominences c. Pink, nonpruritic macular rash on the trunk and inner surfaces of extremities d. A negative serum antistreptolysin-O (ASO) titer e. Muffled heart sounds, pericardial friction rub, and reports of chest pain -Correct Answers: Nontender, subcutaneous nodules over bony prominences, Pink, nonpruritic macular rash on the trunk and inner surfaces of extremities, CNS involvement (chorea) including involuntary, purposeless muscle movements, Muffled heart sounds, pericardial friction rub, and reports of chest pain A nurse is caring for a 2-month-old client who is experiencing cough, wheezing, nasal congestion, fever, difficulty feeding and increased respiratory rate. Which of the following diagnosis should the nurse anticipate? Select one: a. Asthma b. Croup c. Epiglottitis d. Respiratory Syncytial Virus -Correct Answers: d. Respiratory Syncytial Virus The manifestations presented reflect bronchiolitis/RSV which is most common in infants 2-12 months of age. A nurse is providing discharge instructions to the parents of a child with sickle cell disease. Which of the following should be included? Select all that apply. Select one or more: a. Manifestations of crisis and infection. b. The need to maintain up-to-date immunizations. c. Reinforcement of fluid intake requirements. d. Ways to promote rest and adequate nutrition. e. Encourage participation in contact sports. -Correct Answers: Manifestations of crisis and infection., Ways to promote rest and adequate nutrition., The need to maintain up-to-date immunizations., Reinforcement of fluid intake requirements. A nurse is caring for a child following a tonsillectomy. Which of the following nursing interventions should be included in the postoperative care? Select one: a. Avoid red-colored liquids and milk-based foods. b. Encourage the child to blow nose gently. c. Notify the provider if blood-tinged mucus are observed in emesis. d. Position the child supine. -Correct Answers: a. Avoid red-colored liquids and milk-based foods. Following a tonsillectomy clear liquids and fluids should be encouraged after a return of the gag reflex. Red-colored liquids and milk-based foods should be avoided initially, and then the diet should be advanced with soft, bland foods. Which of the following vaccines are administered to protect an infant from bacterial meningitis? Select all that apply. Select one or more: a. Inactivated polio vaccine (IPV) b. Trivalent inactivated influenza vaccine (TIV) c. Pneumococcal conjugate vaccine (PVC) d. Haemophilus influenzae type B vaccine (Hib) e. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) -Correct Answers: Pneumococcal conjugate vaccine (PVC), Haemophilus influenzae type B vaccine (Hib) A 5-year-old cystic fibrosis client is admitted. Which body system assessment will the nurse prioritize to complete initially? Select one: a. Urinary b. Respiratory c. Integumentary d. Gastrointestinal -Correct Answers: b. Respiratory Cystic fibrosis is a respiratory disorder that results from inheriting a mutated gene. The nurse should first assess the respiratory system. Which of the following clients can provide their own informed consent? Select one: a. 12-year-old with leukemia b. 4-year-old with croup c. 17-year-old who is married d. 8-year-old with cystic fibrosis -Correct Answers: c. 17-year-old who is married. A 17-year-old who is married is an emancipated minor and can provide informed consent for themselves. A client taking methylphenidate should avoid which of the following? Select one: a. Fiber-rich foods b. Alcohol CorrectCorrect. Methylphenidate is a central nervous system stimulant that should not be taken with alcohol or any medication, even over the counter medications without the provider's approval. c. Foods with tyramine d. Calcium-rich foods -Correct Answers: b. Alcohol Methylphenidate is a central nervous system stimulant that should not be taken with alcohol or any medication, even over the counter medications without the provider's approval. A 7-year-old client has developed meningitis after a traumatic accident. What isolation precautions will be put in place? Select one: a. Droplet CorrectCorrect. Isolate the client as soon as meningitis is suspected, and maintain droplet precautions per facility protocol. b. Airborne c. Contact d. Universal -Correct Answers: a. Droplet Isolate the client as soon as meningitis is suspected, and maintain droplet precautions per facility protocol. Which injury prevention measure for poisoning will help preserve home safety recommendation? Select one: a. A working carbon monoxide detector should be kept in the home. b. Anchor heavy objects and furniture so they cannot be overturned. c. Secure fence around pool. d. The temperature of the bath should be assessed. -Correct Answers: a. A working carbon monoxide detector should be kept in the home. To preserve home safety it is important to have a working carbon monoxide detector in the home. A client with osteomyelitis has severe pain. Which medication, administered by the nurse is most appropriate to manage pain? Select one: a. Sumatriptan b. Acetaminophen c. Morphine d. Methotrexate -Correct Answers: c. Morphine Morphine is used for severe pain associated with osteomyelitis. Acetaminophin is used for mild pain. Methotrexate is primary used for autoimmune conditions to stop the progression of the autoimmune process. Sumatriptan is a serotonin receptor agonist that helps with migraine headache pain. A 7-month-old is admitted for suspected shaken baby syndrome. Which nursing action is most appropriate? Select one: a. Assist client with maintaining self-image. b. Document assessment information objectively. c. Maintain low continuous suction. d. Administer morphine. -Correct Answers: b. Document assessment information objectively. Clearly and objectively document information obtained in the interview and during the physical assessment is imperative. What is a contributing factor associated with conduct disorder for an 11-year-old client that the nurse should be aware of? Select one: a. Untreated depression b. Being female c. Parent with a history of psychological illness d. Eating disorder -Correct Answers: c. Parent with a history of psychological illness. Conduct disorder has an association with parental history of psychological illness. A client with autism is taking desipramine. The nurse provides teaching to the parents of the client regarding adverse effects. Which statement by the client's parent demonstrates understanding of the teaching? Select one: a. "We will limit our son's beverage consumption since this medication is a diuretic." b. "Because this medication can effect vision, we will have our son wear sunglasses." c. "We will limit from our son's diet whole grain to prevent stomach issues." d. "We will not discontinue the medication abruptly because it can lead to bleeding." -Correct Answers: b. "Because this medication can effect vision, we will have our son wear sunglasses." Desipramine has anticholinergic such as dry mouth, blurred vision, photophobia, urinary hesitancy or retention, constipation, tachycardia. A nurse is helping parent's select appropriate independent activities for their 8 year old child. Which of the following would be an appropriate activity? Select one: a. Allowing the child to play video games b. Playing touch football c. Providing frequent trips to the library d. Encouraging the child to assume care of the family pet -Correct Answers: c. Providing frequent trips to the library Providing frequent trips to the library allows the child to select reading material that is stimulating and reading is an independent activity.