ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
In terms of gross motor development, which should the nurse expect a 5-month-old infant to do? (Select all that apply.)
Correct Answer: A
Rationale: At 5 months old, an infant would typically be able to roll from abdomen to back (Choice A). This is an important gross motor skill that develops during this stage. Additionally, putting their feet in their mouth when lying on their back (Choice B) is also a common movement seen at this age. Both these actions demonstrate the increasing strength and coordination of the infant's muscles as they develop and explore their physical abilities. Rolling from back to abdomen (Choice C) and sitting erect without support (Choice D) typically develop later, around 6-7 months and 8-9 months, respectively. Moving from prone to sitting position (Choice E) and adjusting posture to reach an object (Choice F) are usually mastered around 8-9 months as well.
Question 2 of 5
Samantha, age 5 years, tells the nurse that she "needs a Band-Aid" where she had an injection. Which is the best nursing action?
Correct Answer: C
Rationale: The best nursing action in this scenario is to explain why a Band-Aid is not needed. At 5 years old, Samantha is at an age where she can begin to understand explanations. By providing her with a simple and clear explanation, the nurse can help Samantha understand that a Band-Aid is not necessary in this situation. This also promotes education and helps Samantha learn about wound healing and appropriate care. It is important to involve the child in the decision-making process and provide education to foster their understanding of their own health.
Question 3 of 5
Which should the nurse anticipate in the newborn whose mother used cocaine during pregnancy?
Correct Answer: C
Rationale: When a newborn's mother uses cocaine during pregnancy, the baby may experience cardiac and respiratory problems. Cocaine can negatively impact the development of the baby's cardiovascular system, potentially leading to issues such as abnormal heart rhythms, increased blood pressure, and even heart attacks in severe cases. Additionally, cocaine can also affect the respiratory system, putting the newborn at risk of breathing difficulties or even respiratory distress. Therefore, it is crucial for the nurse to anticipate these potential complications and provide appropriate monitoring and care to address any cardiac and respiratory issues that may arise in a newborn exposed to cocaine in utero.
Question 4 of 5
What is the best initial action for the nurse to take?
Correct Answer: A
Rationale: The best initial action for the nurse to take when a client is experiencing hyperventilation is to try to have the client breathe slower. This is because hyperventilation is often caused by rapid, shallow breathing and slowing down the breathing pattern can help restore normal gas exchange and alleviate symptoms. Providing oxygen via a nasal cannula or administering sodium bicarbonate would not directly address the underlying issue of hyperventilation. Monitoring fluid balance is important for overall assessment but not the priority when dealing with acute respiratory distress due to hyperventilation.
Question 5 of 5
In JRA, the autoimmune reaction primarily occurs in the:
Correct Answer: C
Rationale: In Juvenile Rheumatoid Arthritis (JRA), which is now referred to as Juvenile Idiopathic Arthritis (JIA), the autoimmune reaction primarily occurs in the synovial tissue of the joints. The synovial tissue lines the inside of the joint capsule and produces synovial fluid, which helps to lubricate and nourish the joint. In JIA, the immune system mistakenly targets the synovial tissue, leading to inflammation, pain, and damage to the joints. This inflammatory process can result in swelling, warmth, stiffness, and eventual joint destruction if left untreated. Therefore, the synovial tissue is the primary site of the autoimmune reaction in JRA/JIA.