ATI RN
ATINur2708 Pediatrics Final Exam Questions
Extract:
11-month-old infant reportedly fell down a flight of stairs from the porch to the sidewalk. CT scan shows small subdural hematoma. Admit for close observation. Vital Signs Admission: Axillary temperature 37.1° C (98.8° F), Apical heart rate 104/min, Respiratory rate 26/min, Oxygen saturation 98% on room air. 4 hr later: Axillary temperature 38.2° C (100.8° F), Apical heart rate 124/min, Respiratory rate 22/min, Oxygen saturation 96% on room air. Nurses' Notes Admission note: Infant alert and fussy in guardian's arms. Moves all extremities. Edema and ecchymosis noted on left side of scalp. Anterior fontanel level and soft. Pupils equal and react briskly to light. 4 hr later: Infant sleeping in guardian's arms. Guardian reports they are unable to wake the infant to feed them. Infant slept through vital sign assessment.
Question 1 of 5
A nurse is caring for an infant in the emergency department. Which of the following actions should the nurse take?
Correct Answer: A,B,C,E
Rationale: The correct actions for the nurse to take are stabilizing the infant's spine (
A), palpating fontanel level (
B), assessing pupillary reaction to light (
C), and measuring the infant's head circumference (E). Stabilizing the spine is crucial in cases of trauma to prevent further injury. Palpating fontanel level helps assess for dehydration or intracranial pressure. Assessing pupillary reaction to light is a neurological assessment to check for any abnormalities. Measuring head circumference is important for monitoring growth and detecting any abnormalities. Encouraging feeding (
D) and evaluating for Babinski reflex (F) are not immediate priorities in an emergency setting and can be addressed later.
Extract:
11-year-old diagnosed 2 years ago with tonic-clonic seizure disorder. Three months ago, neurologist changed the child's antiepileptic medications to include Phenytoin due to increasing number of seizures per guardian. Diagnostic Results 1030: WBC count 8,500/mm3, RBC count 4.2, Hemoglobin 11 g/dL, Hematocrit 40%, Platelet count 216,000/mm3, Phenytoin Level: 6 mcg/mL (10 to 20 mcg/mL), Liver Enzymes: ALT 32units/L, ALP 240units/L, AST 44units/L, Albumin 4.1 g/dL, Total protein 6.5, Direct bilirubin 0.3 mg/dL, Indirect bilirubin 0.8 mg/dL. Vital Signs 0900: Temperature 36.8° C (98.2° F), Heart rate 80/min, Respiratory rate 22/min, Blood pressure 116/78 mm Hg, SaO2 94% on room air. Nurses Notes 0900: Child reports a harsh non-productive cough worse when playing outside and at night, feels short of breath during coughing episodes. Guardian reports 3 seizures over the past week, last one yesterday morning, tonic-clonic, lasted 2 minutes. Child is alert, oriented. Noted dry, hyperpigmented, patchy, itchy skin in antecubital area with scratch marks and dried blood. Child has a 1-year history of mild exercise-induced asthma, prescribed albuterol prn.
Question 2 of 5
The client is at risk for developing due to .
Correct Answer: A,B
Rationale: The correct answer is A and B. Stevens-Johnson syndrome is a severe skin reaction characterized by rash, blisters, and skin peeling. The client is at risk for developing Stevens-Johnson syndrome due to certain medications, infections, or underlying medical conditions. Skin rash is also a common symptom of Stevens-Johnson syndrome. Other choices are incorrect as they do not specifically relate to the risk factors or manifestations of Stevens-Johnson syndrome.
Extract:
Question 3 of 5
The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?
Correct Answer: A
Rationale: The correct answer is A. This statement indicates a lack of understanding because it is normal for adolescents to prefer spending time with friends rather than family as they develop independence. This behavior alone does not necessarily indicate depression.
Choices B, C, and D are potential signs of depression in adolescents and would not require further education. Weight changes, excessive sleep, and decline in academic performance are commonly associated with depression in this age group.
Extract:
Child with hemiplegic cerebral palsy.
Question 4 of 5
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Modify the environment. This is the priority goal because adapting the environment to meet the child's needs is crucial for safety and optimizing function in hemiplegic cerebral palsy. By modifying the environment, the nurse can reduce physical barriers and enhance the child's independence.
Choices B, C, and D are important but are secondary to environmental modifications in this case. Foster self-care activities and improve communication skills are valuable goals but are not as immediate as ensuring a safe and supportive environment. Providing respite services for parents is also important but is not the priority when considering the child's direct care needs.
Extract:
Adolescent with spina bifida, paralyzed from the waist down.
Question 5 of 5
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?
Correct Answer: B
Rationale: The correct answer is B. The client stating they only need to catheterize twice a day indicates a need for further teaching because individuals with paralysis from spina bifida may need to catheterize more frequently to prevent urinary retention and complications. The nurse should educate the client on the importance of regular catheterization to maintain bladder health.
Choice A is correct as it demonstrates the client's engagement in physical activity, which is important for overall health.
Choice C indicates the client is aware of the importance of staying hydrated.
Choice D shows the client's understanding of managing bowel movements, which is also crucial.