Ati paediatrics unit 2 exam
Total Questions : 56
Showing 25 questions, Sign in for moreA nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?
Explanation
A. A stool fat content analysis can suggest malabsorption issues but does not specifically confirm cystic fibrosis.
B. The sweat chloride test measures the amount of chloride in the sweat, with elevated levels confirming a diagnosis of cystic fibrosis.
C. Pulmonary function tests assess lung function but are not definitive for diagnosing cystic fibrosis.
D. A sputum culture can identify respiratory infections but is not specific for cystic fibrosis diagnosis.
A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?
Explanation
A. The ASO titer does not measure therapeutic levels of aminoglycosides; this response is incorrect.
B. The ASO titer is not a direct diagnostic test for rheumatic fever but indicates a recent infection with streptococcal bacteria, which can lead to rheumatic fever.
C. The test does not confirm immunity but rather measures antibodies against streptolysin O, indicating recent infection.
D. An elevated ASO titer confirms that the child had a recent streptococcal infection, which is important in diagnosing rheumatic fever.
A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?
Explanation
A. This option is incorrect as it does not describe the expected blood pressure difference in coarctation of the aorta.
B. Coarctation of the aorta typically presents with higher blood pressure in the upper body (arms) and lower blood pressure in the lower body (legs) due to the obstruction of blood flow distal to the aortic arch.
C. This option is incorrect because while coarctation can lead to decreased perfusion in the lower extremities, it does not typically result in decreased blood pressure in both the arms and legs simultaneously.
D. While increased blood pressure may occur in the arms, the legs would not typically show increased blood pressure in cases of coarctation.
A nurse and a newly licensed nurse are providing care for a client who has distributive shock related to an anaphylactic reaction. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?
Explanation
A. Distributive shock, particularly in the context of anaphylaxis, is characterized by widespread vasodilation that leads to a decrease in systemic vascular resistance and impaired blood flow to organs despite normal or increased cardiac output.
B. This option is incorrect because distributive shock involves decreased systemic vascular resistance due to vasodilation rather than an increase.
C. This statement describes hypovolemic shock, not distributive shock. Distributive shock is not primarily caused by the loss of blood volume.
D. While loss of myocardial contractility can lead to cardiogenic shock, it is not the mechanism behind distributive shock, which is related to vascular tone rather than heart function.
A nurse is caring for a client who just returned from a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)
Explanation
A. It is important for the client to remain in bed for a specified time (typically 4 to 6 hours) to prevent complications such as bleeding at the catheter insertion site.
B. Checking peripheral pulses in the affected extremity is crucial for assessing circulation and identifying any potential complications, such as hematoma or occlusion.
C. High-Fowler's position is not typically appropriate immediately after cardiac catheterization; the client should remain flat or with limited elevation to reduce stress on the insertion site.
D. Keeping the hip and leg extended is important to prevent flexion at the site of catheter insertion, reducing the risk of bleeding or hematoma formation.
E. Measuring vital signs is essential after a procedure like cardiac catheterization to monitor for any changes that may indicate complications; however, the frequency is typically more frequent than every 4 hours initially.
A nurse is providing care to an adolescent client who is hospitalized in an adult setting. Which of the following interventions by the nurse supports a client experiencing emotional and physical changes of puberty? (Select all that apply.)
Explanation
A. Providing privacy during personal care and procedures is essential for adolescents, as it helps them feel more secure and respected during a vulnerable time.
B. This option is incorrect; discussing changes related to puberty can help the adolescent understand their body and promote healthy coping mechanisms.
C. Treating the adolescent as if they are not competent undermines their autonomy and can negatively impact their self-esteem; adolescents should be involved in their care and decision-making when appropriate.
D. Disregarding confidentiality can lead to a breakdown of trust; it is important to respect the adolescent's privacy while also keeping parents informed within appropriate limits.
E. Showing respect for the client's feelings and concerns helps validate their experiences and fosters a supportive environment during a challenging time.
F. Listening carefully to the client’s thoughts and concerns encourages open communication, allowing the nurse to address any worries and support the adolescent’s emotional needs.
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?
Explanation
A. While constipation can be a side effect of iron supplements, taking them between meals is primarily aimed at improving absorption rather than preventing constipation.
B. Taking iron supplements with food does not specifically increase the risk of esophagitis; instead, it is known to interfere with the absorption of iron.
C. Taking ferrous sulfate between meals optimizes its absorption because food, particularly dairy products, caffeine, and some high-fiber foods, can inhibit the absorption of iron.
D. Although iron supplements can cause nausea, it is more effective to take them between meals for better absorption rather than solely to prevent nausea.
A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?
Explanation
A. The child should avoid tub baths or submerging in water for several days post-procedure to reduce the risk of infection and keep the catheter site dry; sponge baths are usually recommended.
B. Keeping the child home for an entire week may be excessive; the duration of home care typically depends on the child's recovery, and many children can return to school sooner if they feel well.
C. Offering clear liquids for the first 24 hours helps ensure the child stays hydrated and allows for easier digestion following anesthesia or sedation.
D. Giving acetaminophen for discomfort is appropriate, as it can help manage any pain or discomfort the child may experience after the procedure, and is usually a recommended practice.
Which of the following cognitive abilities are characteristic of a school-aged child in Piaget's concrete operational stage? (select all that apply)
Explanation
A. Object permanence is a cognitive ability typically developed during the sensorimotor stage (0-2 years), not during the concrete operational stage (7-11 years).
B. Egocentric thinking is characteristic of the preoperational stage (2-7 years) and decreases as children enter the concrete operational stage.
C. The ability to perform logical operations on concrete objects is a hallmark of the concrete operational stage, where children can think logically about physical objects and events.
D. Understanding the concept of conservation, which refers to recognizing that quantity does not change despite changes in shape or arrangement, is a key characteristic of the concrete operational stage.
E. Use of symbolic play is more characteristic of the preoperational stage, where children engage in imaginative play rather than concrete operations.
A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?
Explanation
A. The meningococcal (MCV4) vaccine is typically recommended for preteens and adolescents, usually starting at age 11.
B. The hepatitis B vaccine is typically administered at birth, 1-2 months, and 6-18 months, so a 4-year-old may already have received this vaccine.
C. The varicella (VAR) vaccine is recommended for children at ages 12-15 months and again at 4-6 years, making it appropriate for a 4-year-old child.
D. The Haemophilus influenza type b (Hib) vaccine is usually given to children in a series before 5 years of age, but it is more commonly completed by age 2-3 years. The 4-year-old may already be up to date with this vaccine.
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?
Explanation
A. Taking ferrous sulfate between meals may actually help reduce the risk of constipation, but this is not the primary reason for timing.
B. Taking the medication with food does not typically increase the risk of esophagitis; rather, it can decrease the absorption of iron.
C. Taking ferrous sulfate between meals allows for optimal absorption of iron, as food can interfere with its absorption. This response accurately explains the rationale for the timing of the medication.
D. While it is true that some patients may experience nausea when taking iron supplements with food, the primary reason for taking it between meals is to enhance absorption rather than to prevent nausea.
A nurse is analyzing a client's electrocardiogram (ECG) strip and identifies the following information: Heart rate: 92/min Rhythm: Irregular P wave:
Unable to identify PR interval:
Unable to measure QRS duration:
0.10 seconds Based upon this information,
thenurse should interpret the client's rhythm as indicating which of the following?
Explanation
A. Supraventricular tachycardia (SVT) typically has identifiable P waves; the absence of P waves suggests a different condition.
B. Atrial fibrillation is characterized by an irregular rhythm, inability to identify P waves, and varying intervals. This interpretation aligns with the client's ECG findings.
C. Sinus bradycardia would show identifiable P waves and a regular rhythm with a heart rate less than 60 bpm, which does not match the provided information.
D. First-degree heart block would also show identifiable P waves and regularity in the rhythm with a prolonged PR interval, which is not indicated here.
A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?
Explanation
A. Doubling the dose if a dose is missed can increase the risk of bleeding and is not recommended for warfarin. Instead, the client should take the missed dose as soon as remembered unless it's almost time for the next dose.
B. Using an electric razor is recommended to minimize the risk of cuts and bleeding, which is particularly important for clients on anticoagulants like warfarin.
C. While increasing fiber intake can be beneficial for overall health, it is not specifically necessary for addressing constipation related to warfarin therapy.
D. While mild nosebleeds may occur, they are not typically common during initial treatment. Clients should be informed to report any unusual or severe bleeding.
A nurse is preparing to administer digoxin to a pediatric client who has heart failure. Which of the following actions is appropriate?
Explanation
A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.
B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.
C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.
D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.
A nurse is providing care for a group of hospitalized school-aged children. Which of the following clients should the nurse prioritize for further assessment and interventions?
Explanation
A. While anxiety and withdrawal are concerning, they may not require immediate intervention compared to behaviors that pose risks to the child or others.
B. A stable child with a concerned parent may benefit from reassurance and support, but they do not require urgent intervention.
C. Stomach pain without an apparent cause should be assessed, but it may not be as urgent as aggressive behavior that can harm others.
D. A child exhibiting aggressive behavior poses a risk to themselves and others, necessitating immediate assessment and intervention to ensure safety and manage the behavior effectively.
A nurse is caring for a child who is suspected of having pertussis. The nurse should recognize that the pathophysiology of pertussis includes which of the following?
Explanation
A. Pertussis primarily affects the respiratory tract rather than just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making it a bacterial infection, not viral.
C. The bacteria release toxins that damage the cilia of the epithelial cells in the respiratory tract, disrupting their function.
D. Inflammation occurs in the lungs and airway due to the infection, contributing to symptoms such as cough.
E. The infection leads to excessive secretions that are difficult to expel, resulting in the characteristic whooping cough associated with pertussis.
A nurse is providing care to a school-aged child who has uncontrolled asthma. The child's parent does not seem engaged in the child's treatment during the hospitalization and states that the child manages their care with little assistance from them. Which of the following nursing interventions is most appropriate?
Explanation
A. While child protective services may be necessary in cases of abuse or neglect, it is premature to take this action without understanding the family's dynamics and assessing the parent’s knowledge and skills regarding asthma management.
B. Providing a detailed medication schedule and healthcare provider information is helpful but does not actively engage the parent in the child's care or education about asthma management.
C. Empowering the parent through comprehensive education will foster engagement and collaboration, equipping them with the knowledge needed to support their child's asthma management effectively at home.
D. Reviewing the asthma action plan is important, but it should involve both the child and parent to ensure that the parent is actively engaged and understands how to implement the plan.
A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?
Explanation
A. This statement is incorrect; the spacer does not primarily increase medication delivery to the oropharynx.
B. The spacer helps to increase the amount of medication that reaches the lungs by allowing larger particles to settle out and preventing them from being deposited in the mouth and throat.
C. Inhaling slowly and deeply is recommended for effective medication delivery when using an MDI with a spacer.
D. Covering the exhalation slots would prevent proper airflow and could cause the child to inhale exhaled air, which is not recommended during inhalation.
A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse expect to administer first?
Explanation
A. Montelukast is a leukotriene receptor antagonist used for long-term management and prevention of asthma symptoms, not for acute relief.
B. Budesonide is an inhaled corticosteroid used for long-term control of asthma but does not provide immediate relief during an acute attack.
C. Albuterol is a short-acting beta-agonist (SABA) that provides rapid bronchodilation and is the first-line medication for relieving acute asthma symptoms.
D. Fluticasone is also an inhaled corticosteroid intended for long-term management, which does not address the immediate needs of an acute asthma attack.
A nurse is caring for a child who is suspected of having pertussis. The nurse should recognize that the pathophysiology of pertussis includes which of the following? (Select All that Apply.)
Explanation
A. Pertussis, or whooping cough, primarily affects the respiratory tract, particularly the trachea and bronchi, not just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making this statement incorrect as the infection is bacterial, not viral.
C. The toxins released by Bordetella pertussis damage the cilia of epithelial cells in the respiratory tract, leading to difficulty in clearing secretions.
D. The inflammation of the lungs and airways is a characteristic response to the infection, contributing to the symptoms of coughing and difficulty breathing.
E. The production of thick, mucus secretions is a hallmark of pertussis, which makes it challenging for the child to expel them, leading to severe coughing fits.
A nurse is planning a community health program for school-age children. According to Erikson's theory of psychosocial development, which activity would best support the developmental task of this age group?
Explanation
A. Solitary play is more characteristic of earlier stages of development, such as infancy and early childhood. School-age children benefit more from social interactions.
B. While academic achievements are important, focusing solely on individual success does not support the social skills that are essential for this developmental stage.
C. Encouraging participation in team sports promotes social interaction, teamwork, and a sense of belonging, which are crucial for developing competence and self-esteem during this stage.
D. Promoting dependence on parents goes against the developmental task of this age group, which is to foster independence and decision-making skills.
nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?
Explanation
A. Visualizing the epiglottis with a tongue depressor is contraindicated in suspected epiglottitis due to the risk of triggering airway obstruction.
B. Transporting the child to radiology for a throat x-ray is not a priority and can delay necessary interventions.
C. Obtaining a throat culture is not appropriate in this situation, as airway compromise can occur quickly, and immediate management is crucial.
D. Placing the child in an upright position helps ease breathing and can alleviate distress, which is vital for a child with suspected epiglottitis.
A nurse is caring for a toddler who is experiencing an acute asthma attack. Which of the following findings indicates improvement?
Explanation
A. Improved hydration is important but not directly indicative of an asthma attack improvement.
B. A barking cough is often associated with conditions like croup and does not indicate improvement in asthma symptoms.
C. Decreased temperature is not a specific indicator of improvement in asthma and may not correlate with the severity of an asthma attack.
D. Decreased stridor indicates a reduction in airway obstruction and inflammation, signifying an improvement in the child’s respiratory status during an asthma attack.
Which of the following are common manifestations and potential consequences of an adolescent's feelings of invulnerability? (Select all that apply)
Explanation
A. Increased risk-taking behaviors are common as adolescents may feel invulnerable and engage in dangerous activities without considering the consequences.
B. Greater incidence of accidental injuries is often a result of risk-taking behaviors, which can be influenced by feelings of invulnerability.
C. Reduced mental health issues is incorrect as feelings of invulnerability can lead to increased stress and anxiety, negatively impacting mental health.
D. Improved social relationships are not guaranteed; feelings of invulnerability may actually lead to conflict or isolation if risk-taking behaviors are harmful.
E. Higher likelihood of substance abuse can result from a belief in invulnerability, leading adolescents to underestimate the risks associated with drug and alcohol use.
F. Enhanced academic performance is not directly linked to feelings of invulnerability and may suffer due to distractions from risky behaviors.
What is the priority nursing intervention for a newborn infant diagnosed with transposition of the great vessels?
Explanation
A. Preparing for immediate surgery is necessary, but the priority intervention is to ensure adequate oxygenation and blood flow through the ductus arteriosus before surgery can be performed.
B. Initiating feeding through a nasogastric tube is not a priority for an infant with this condition, as their immediate need is to address the circulatory issue rather than feeding.
C. Administering oxygen via nasal cannula may provide some relief but is not sufficient as a standalone intervention for transposition of the great vessels, which requires maintaining ductal patency to allow mixing of oxygenated and deoxygenated blood.
D. Administering prostaglandin E1 (PGE1) is the priority intervention, as it helps maintain patency of the ductus arteriosus, allowing for temporary stabilization of the infant’s condition until surgical intervention can be performed.
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