ATI RN
ATI RN Nursing Care of Children 2019 Questions
Extract:
10-month-old child following a head injury
Question 1 of 5
A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Assess respiratory status. This is the first action the nurse should take as airway and breathing are the top priorities in any emergency situation. Ensuring the child has a patent airway and is breathing adequately is crucial for their survival. Assessing respiratory status includes observing for signs of distress, such as increased respiratory rate, use of accessory muscles, and abnormal breath sounds. This initial assessment will help the nurse determine the child's immediate needs and guide further interventions.
Inspecting for fluid leaking from the ears (
B) and examining the scalp for lacerations (
C) are important assessments but should come after ensuring the child's respiratory status is stable. Checking pupil reactions (
D) is also important but not as immediate as assessing respiratory status in this scenario.
Extract:
Preschooler refusing oral diphenhydramine
Question 2 of 5
A nurse is caring for a preschooler who refuses to take a stat dose of oral diphenhydramine. Which of the following statements should the nurse make?
Correct Answer: C
Rationale:
Correct
Answer: C. The medication will treat your hypersensitivity reaction.
Rationale: This statement provides a clear explanation of the purpose of the medication, making it more likely for the preschooler to understand the need for taking it. It promotes understanding and cooperation by linking the medication to treating a specific condition. This approach helps build trust and compliance with the treatment plan.
Summary of Incorrect
Choices:
A: The statement is inaccurate and may mislead the child into thinking the medication is safe to consume in large amounts.
B: This statement puts the responsibility on the child to initiate medication administration, which may not be effective in this situation.
D: This statement introduces an unnecessary emotional element that may confuse or distract the child from the purpose of the medication.
Extract:
Infant with rotavirus
Question 3 of 5
A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?
Correct Answer: C
Rationale: The correct answer is C: Weight loss 7%. Moderate dehydration is typically indicated by a weight loss of around 5-10%. In infants, weight loss is a more reliable indicator of dehydration as compared to other signs like capillary refill or bradycardia. Respiratory rate and capillary refill time can be influenced by factors other than dehydration, while bradycardia is not a consistent finding in moderate dehydration. Weight loss directly reflects fluid loss and is a key parameter to assess dehydration in infants.
Extract:
12-year-old client during a well-child visit
Question 4 of 5
A nurse in a provider's office is preparing to administer immunizations to a 12-year-old client during a well-child visit. Which of the following immunizations should the nurse plan to administer?
Correct Answer: D
Rationale: The correct answer is D: Human papillomavirus (HPV) vaccine. The HPV vaccine is recommended for both boys and girls starting at age 11-12. It helps prevent HPV infections that can lead to various cancers. Hepatitis, varicella, and DTaP vaccines are typically administered earlier in childhood. HPV vaccine is important to be given at this age to provide protection before potential exposure. Administering HPV vaccine at 12 years old aligns with CDC and AAP guidelines.
Extract:
School-age child with heart failure taking furosemide
Question 5 of 5
A nurse is assessing a school-age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
Correct Answer: A
Rationale: The correct answer is A: decrease in peripheral edema. Furosemide is a loop diuretic that helps the body get rid of excess fluid and salt through increased urine output.
Therefore, a decrease in peripheral edema indicates that the medication is effective in reducing fluid volume overload, a common manifestation of heart failure.
Choices B, C, and D are incorrect because a decrease in cardiac output, increase in venous pressure, and increase in potassium levels are not desirable outcomes when treating heart failure with furosemide.