ATI PN nursing care of children 2020 with NGN II
Total Questions : 63
Showing 25 questions, Sign in for moreA nurse is reinforcing teaching about accidental drowning with the parents of a toddler. Which of the following information should the nurse include in the teaching?
Explanation
Choice A reason:
While teaching a child to swim is valuable and can potentially reduce the risk of drowning, it does not eliminate the risk entirely. Even proficient swimmers, especially young children, should always have adult supervision near water.
Choice B reason:
Correct. This statement emphasizes a crucial safety measure. A responsible adult should always remain within arm's reach of a young child near water to prevent accidental drowning.
Choice C reason:
This statement is not entirely accurate. Accidental drownings can occur in various water bodies, including pools, bathtubs, and even small containers of water.
Choice D reason:
While placing a fence around a pool is an important safety measure, it is not the only precaution necessary. Adult supervision is still crucial, and the fence alone may not guarantee safety if a child gains access to the pool area.
A nurse is reviewing the medical record of a school-age child who was admitted for suspected physical maltreatment. Which of the following findings in the child's medical history should the nurse identify as a potential risk factor for physical maltreatment?
Explanation
Choice A reason:
Being adopted is not inherently a risk factor for physical maltreatment. It is essential to assess various factors in the child's environment and relationships.
Choice B reason:
Correct. Premature infants may face additional stressors and vulnerabilities, which can sometimes contribute to a higher risk of physical maltreatment. This is an important consideration in the assessment of suspected maltreatment.
Choice C reason:
Myopia (nearsightedness) is a visual impairment and is not directly associated with an increased risk of physical maltreatment.
Choice D reason:
Acute otitis media (ear infection) is a common childhood ailment and is not directly linked to an increased risk of physical maltreatment.
A nurse is reviewing the medical records of a group of toddlers. The nurse should identify that which of the following conditions is a notifiable infectious disease?
Explanation
Choice A reason:
Roseola infantum is a common viral illness in infants and young children, but it is not considered a notifiable infectious disease.
Choice B reason:
Correct. Measles is a notifiable infectious disease. This means that healthcare providers are required to report any diagnosed cases to public health authorities due to its potential for outbreaks.
Choice C reason:
Fifth disease, caused by parvovirus B19, is typically a mild viral illness in children and is not classified as a notifiable infectious disease.
Choice D reason:
Scabies is a parasitic infestation, not an infectious disease. It is caused by the Sarcoptes scabiei mite and is not considered notifiable.
A nurse is assisting with the care of a 2-month-old infant who has a subdural hematoma. Which of the following findings should the nurse expect?
Explanation
Choice A reason:
A subdural hematoma may not directly affect the fontanels. Depressed fontanels can be a sign of dehydration or other underlying conditions, but they are not specifically associated with a subdural hematoma.
Choice B reason:
A subdural hematoma would not typically cause a decrease in body temperature. This finding may be related to other factors, but it is not a characteristic sign of a subdural hematoma.
Choice C reason:
Correct. A subdural hematoma is a collection of blood between the dura mater and the brain. This can lead to increased intracranial pressure and result in the infant being difficult to arouse.
Choice D reason:
While a weak cry can be an indication of distress or illness in an infant, it is not a specific sign of a subdural hematoma. Other assessments, including neurological signs, are crucial in evaluating the infant's condition.
A nurse is collecting data from a school-age child who has Cushing's syndrome. Which of the following findings should the nurse expect?
Explanation
Choice A reason:
Hypersomnia (excessive sleepiness) is not a typical finding in Cushing's syndrome. Instead, children with Cushing's syndrome may experience insomnia or disrupted sleep patterns.
Choice B reason:
Hypotension (low blood pressure) is not a characteristic finding in Cushing's syndrome. Elevated blood pressure is more commonly associated with this condition.
Choice C reason:
Rapid weight loss is not a typical finding in Cushing's syndrome. Instead, children with Cushing's syndrome may experience weight gain, particularly in the face (moon face), abdomen, and upper back.
Choice D reason:
Correct. Rounded facial features, often referred to as "moon face," are a characteristic finding in children with Cushing's syndrome. This is due to the redistribution of fat in the body, particularly in the face and trunk.
A nurse is collecting data from a 3-year-old child. Which of the following developmental milestones should the nurse expect the child to demonstrate?
Explanation
Choice A reason:
Using four words in a sentence is an appropriate developmental milestone for a 3-year-old child. By this age, children typically have a vocabulary that allows them to form short sentences and express themselves.
Choice B reason:
Tying shoelaces is a fine motor skill that is typically developed later, around 5-6 years of age.
Choice C reason:
Skipping on alternate feet is a gross motor skill that is typically developed around 4-5 years of age.
Choice D reason:
Naming the days of the week is a cognitive skill that is typically developed later, around 5-6 years of age. It involves not only memory but also an understanding of the concept of days and their order.
A nurse is reinforcing teaching with the parents of a 2-month-old infant who has gastroesophageal reflux. The parents are feeding the infant formula. Which of the following instructions should the nurse include in the teaching?
Explanation
Choice A reason:
Giving the infant a bottle immediately before bedtime can actually exacerbate gastroesophageal reflux, as lying down right after feeding can increase the likelihood of regurgitation.
Choice B reason:
Switching to a soy-based formula is not the first-line intervention for gastroesophageal reflux. Additionally, soy-based formulas are not recommended for all infants and should be used under specific circumstances.
Choice C reason:
This statement is correct. Keeping the infant at a 30° angle for 1 hour following each feeding can help reduce the likelihood of gastroesophageal reflux. This position helps gravity keep the stomach contents from flowing back up into the esophagus.
Choice D reason:
Limiting formula feedings to every 6 hours may not be appropriate for a 2-month-old infant, as they typically require more frequent feedings for proper growth and development.
A nurse is caring for an 18-month-old toddler who has acute diarrhea caused by Clostridium difficile bacteria. Which of the following actions should the nurse take?
Explanation
Choice A reason:
Using a bleach-based solution to clean the bedside table is an appropriate measure to prevent the spread of Clostridium difficile bacteria, as bleach is effective in killing spores.
Choice B reason:
While hand sanitizer is useful for killing many types of bacteria and viruses, it may not be as effective against Clostridium difficile spores. Washing hands with soap and water is preferred.
Choice C reason:
Placing the toddler in a negative-airflow room is not necessary for managing Clostridium difficile diarrhea. Standard precautions and proper hygiene are sufficient.
Choice D reason:
Loperamide is not typically recommended for managing Clostridium difficile diarrhea, as it may worsen the condition by slowing down the bowel motility. The primary treatment is discontinuing the antibiotic that caused the infection and, in some cases, using specific antibiotics to target the C. difficile bacteria.
A nurse is assisting with obtaining informed consent from the parent of a toddler who is scheduled for a surgical procedure. Which of the following actions should the nurse take?
Explanation
Choice A reason:
Providing detailed information about the procedure is important, but the first step in obtaining informed consent is to ensure that the parent understands the information. This can be achieved by assessing their understanding.
Choice B reason:
Discussing the benefits of the procedure is part of providing information for informed consent, but it should come after assessing the parent's understanding.
Choice C reason:
Explaining the risks associated with the procedure is important, but the first step is to ensure the parent comprehends this information, which can be achieved through assessment.
Choice D reason:
This statement is correct. Before proceeding with detailed information, it is essential to determine the parent's current understanding of the procedure to ensure they can make an informed decision.
A nurse is reinforcing teaching with a parent of a child who has a sprained wrist. Which of the following interventions should the nurse instruct the parent to implement during the first 12 to 24 hr to minimize swelling?
Explanation
Choice A reason:
Wrapping the extremity loosely with an elastic bandage may provide support but is not specifically aimed at reducing swelling.
Choice B reason:
Applying warm compresses can be beneficial for some types of injuries, but for a sprained wrist, cold compresses are more effective in reducing swelling.
Choice C reason:
This statement is correct. Elevating the extremity above the level of the heart helps to reduce swelling by promoting venous return and reducing blood flow to the affected area.
Choice D reason:
Encouraging active range of motion may be important for rehabilitation, but it is not the initial intervention for minimizing swelling in the first 12 to 24 hours after a sprain.
A nurse is reinforcing teaching with the parents of a child who has infective endocarditis. Which of the following instructions should the nurse include in the teaching?
Explanation
Choice A reason:
Discontinuing antibiotics when the fever has resolved is not an appropriate instruction for a child with infective endocarditis. The full course of antibiotics should be completed.
Choice B reason:
While antibiotics can have side effects, splinter hemorrhages under the child's nails are not a common side effect of antibiotic use for infective endocarditis.
Choice C reason:
Obtaining prophylactic antibiotics for family members is not a standard practice for infective endocarditis.
Choice D reason:
This statement is correct. Antibiotics are needed prior to certain dental procedures for children with infective endocarditis to prevent bacterial endocarditis.
A nurse is reinforcing teaching about infant car seat use with a group of new parents. Which of the following instructions should the nurse include in the teaching?
Explanation
Choice A reason:
Placing a folded blanket to pad the back of the infant's head is not recommended, as it can interfere with the proper fit of the car seat harness and potentially be a safety hazard.
Choice B reason:
This statement is correct. Infant car seats should be positioned at a 30-degree angle to provide optimal support for the infant's head and neck, as well as to prevent airway obstruction.
Choice C reason:
While car seats with a four-point harness do exist, a standard infant car seat typically has a five- point harness system.
Choice D reason:
The retainer clip should be positioned at the level of the infant's armpits to ensure that the harness is snug and secure.
A nurse is reinforcing teaching about sibling adaptation with a parent of a child who has cystic fibrosis. Which of the following instructions should the nurse include in the teaching?
Explanation
Choice A reason:
Avoiding discussing the child's diagnosis with the sibling may create unnecessary secrecy and could hinder the sibling's understanding and coping.
Choice B reason:
Designating one parent to stay at home with the sibling may not be necessary, as both parents can still provide support and care for both children.
Choice C reason:
Avoiding having the sibling visit the child in the facility may isolate them and prevent opportunities for bonding and support.
Choice D reason:
This statement is correct. Encouraging phone calls between the siblings allows them to maintain communication, express their feelings, and support each other during the separation caused by hospitalization.
A nurse is caring for a toddler whose guardian reports multiple episodes of diarrhea. The provider suspects Clostridium difficile. Which of the following actions should the nurse take?
Explanation
Choice A reason:
Collecting a stool specimen for occult blood is not the most relevant test for suspected
Clostridium difficile infection. Stool culture or testing for C. difficile toxins is more appropriate.
Choice B reason:
Conducting a tape test is used to diagnose pinworms, not Clostridium difficile infection.
Choice C reason:
This statement is correct. Obtaining a stool specimen for culture, specifically for C. difficile, is the appropriate action for suspected infection.
Choice D reason:
Drawing a blood culture is not the primary diagnostic test for Clostridium difficile. Stool culture or testing for C. difficile toxins is more appropriate.
A nurse is collecting data from a child who has type 1 diabetes mellitus and has slurred speech, is diaphoretic, and has a blood glucose reading of 45 mg/dL. Which of the following should the nurse administer?
Explanation
Choice A reason:
A diet soft drink does not contain enough sugar to raise the child's blood glucose level quickly. It is not the appropriate choice in this situation.
Choice B reason:
Metformin is a medication used to manage type 2 diabetes, not type 1 diabetes. It would not be effective in treating the low blood sugar (hypoglycemia) in this scenario.
Choice C reason:
Administering insulin would further lower the child's blood glucose level and is contraindicated in cases of hypoglycemia.
Choice D reason:
This statement is correct. A regular soft drink contains sugar and can rapidly increase the child's blood glucose level, effectively treating the hypoglycemia.
A nurse is reinforcing teaching with the parents of a 2-year-old toddler about age-appropriate play activities. Which of the following activities should the nurse recommend?
Explanation
Choice A reason:
Hopscotch requires a level of coordination and balance that may be challenging for a 2-year-old toddler.
Choice B reason:
Finger painting is a creative and age-appropriate activity for a 2-year-old. It allows them to explore colors and textures while developing fine motor skills.
Choice C reason:
Beginner sports may involve activities that are too complex for a 2-year-old to fully understand and participate in.
Choice D reason:
A 30-piece puzzle may be too advanced for a 2-year-old. They may have difficulty manipulating the small pieces and understanding the concept of assembling the puzzle.
A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?
Explanation
Choice A reason:
Reducing fiber intake is not necessary for a client in skeletal traction. Maintaining a balanced diet, including fiber, is important for overall health.
Choice B reason:
The nurse should not lift the traction weights off the floor. The weights must hang freely to provide the necessary traction.
Choice C reason:
Performing passive range-of-motion exercises helps prevent stiffness and muscle atrophy in the affected extremity. This is an important nursing intervention for a client in skeletal traction.
Choice D reason:
Applying protective padding to the pin sites is essential to prevent pressure and irritation. However, this action alone does not address the need for range-of-motion exercises.
A nurse is caring for a child who has mild dehydration due to an Escherichia coli infection. Which of the following actions should the nurse take?
Explanation
Choice A reason:
Encouraging fruit juices is not the best approach for rehydration in a child with mild dehydration. Fruit juices can be high in sugar and may worsen diarrhea.
Choice B reason:
Giving oral rehydration solution in small, frequent amounts is the recommended treatment for mild dehydration due to infection. This helps replace lost fluids and electrolytes.
Choice C reason:
Promethazine is not indicated for the treatment of dehydration. It is an antihistamine and antiemetic, but it does not address the underlying issue of fluid loss.
Choice D reason:
Offering banana and rice can be part of a bland diet after rehydration, but it does not address the immediate need for replenishing lost fluids and electrolytes. The priority is to start with oral rehydration solution.
A nurse is collecting data from an 18-month-old toddler who is postoperative. Which of the following rating scales should the nurse use to identify the toddler's pain level?
Explanation
Choice A reason:
The color tool is not a pain assessment tool; it is used to assess oxygen saturation levels.
Choice B reason:
The FACES scale is commonly used for children who are 3 years of age and older, but it may not be suitable for an 18-month-old toddler who may have limited ability to express pain through facial expressions.
Choice C reason:
The visual analog scale is typically used for older children and adults. It may not be effective for assessing pain in an 18-month-old toddler.
Choice D reason:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a validated pain assessment tool for young children, including toddlers. It evaluates specific behaviors related to pain, making it suitable for this age group.
A nurse is caring for an adolescent who has a lower extremity fracture. Which of the following types of skin traction should the nurse expect the provider to prescribe?
Explanation
Choice A reason:
Bryant traction is used in infants with congenital hip dysplasia. It is not a form of skin traction for lower extremity fractures in adolescents.
Choice B reason:
Cervical skin traction is used for cervical spine injuries or surgeries, not for lower extremity fractures.
Choice C reason:
Dunlop traction is used for fractures of the humerus.
Choice D reason:
Buck extension traction is applied to the lower leg and uses a boot on the affected leg with weights to provide traction. It is commonly used for lower extremity fractures in adolescents.
A nurse is reinforcing teaching about death and dying with the guardians of a preschooler who has a terminal illness. Which of the following statements should the nurse include?
Explanation
Choice A reason:
While some children may have fears associated with death, describing it as a "monster" is not a typical perception of preschoolers.
Choice B reason:
Preschoolers do not generally view death as a temporary type of sleep. This perspective is more common in younger children.
Choice C reason:
Preschoolers often have a natural curiosity about death and may ask questions about what happens to the body after death. It is important to provide honest and age-appropriate
information.
Choice D reason:
Preschoolers may not have a deep understanding of the physical changes that occur during the process of dying. Their curiosity is often focused on more concrete aspects.
A nurse is preparing to administer azithromycin oral suspension 10 mg/kg/day to a 15-month- old infant who has otitis media. The infant weighs 22 Ib. The amount available is azithromycin oral suspension 200 mg/5 mL. How many mL should the nurse plan to administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
- Convert the infant's weight from pounds to kilograms: 22 Ib / 2.2 = 10 kg
- Calculate the daily dose of azithromycin: 10 mg/kg/day x 10 kg = 100 mg/day
- Calculate the volume of azithromycin oral suspension needed: 100 mg/day / (200 mg/5 mL) = 2.5 mL/day
- Round the answer to the nearest tenth: 2.5 mL/day
- The nurse should plan to administer 2.5 mL of azithromycin oral suspension to the infant.
A nurse is preparing to collect a blood specimen from a preschooler. Which of the following actions should the nurse take?
Explanation
Choice A reason:
Using a pacifier dipped in an oral sucrose solution can help provide comfort and alleviate pain during the procedure, making it a suitable option for blood specimen collection in preschoolers.
Choice B reason:
Applying a eutectic mixture of local anesthetics cream may not be the most appropriate option for blood specimen collection in preschoolers, as it may not provide sufficient pain relief for the procedure.
Choice C reason:
Kangaroo care involves skin-to-skin contact between an infant and a parent, which is beneficial for bonding and comfort but may not be directly applicable to a blood specimen collection procedure.
Choice D reason:
Placing the infant in a prone position for sleeping is not related to blood specimen collection and may not be appropriate immediately postoperatively.
A nurse is assisting with the care of a preschooler who is postoperative following tetralogy of Fallot correction. Which of the following manifestations indicates the child is possibly experiencing decreased cardiac output?
Explanation
Choice A reason:
Diminished pulses can be indicative of decreased cardiac output, as it suggests that there may be a reduction in the volume of blood being pumped by the heart.
Choice B reason:
Extremities warm to touch is not necessarily indicative of decreased cardiac output. It may be related to other factors, such as ambient temperature or local blood flow.
Choice C reason:
Capillary refill of 2 seconds is within the normal range for a preschooler, and it is not a strong indicator of decreased cardiac output.
Choice D reason:
A blood pressure of 112/66 mm Hg is within the normal range for a preschooler and is not a strong indicator of decreased cardiac output.
A nurse is preparing to administer a tube feeding to a child who has an NG tube. Which of the following actions should the nurse take?
Explanation
Choice A reason:
Connecting a bulb attachment to the syringe is not a standard method for administering a tube feeding and can potentially lead to complications.
Choice B reason:
Heating the formula to body temperature is not typically necessary and can be potentially dangerous if it leads to overheating.
Choice C reason:
Positioning the child with the head of the bed elevated at 15° helps to prevent aspiration during tube feeding.
Choice D reason:
Instilling the feeding based on pH alone is not a sufficient criterion for administration. Other factors, such as radiographic confirmation of tube placement, should also be considered.
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