ATI RN
NCLEX Pediatric Respiratory Nursing Questions Questions
Question 1 of 5
Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome?
Correct Answer: B
Rationale: In this scenario, the most appropriate action for the nurse to take first is to select option B: Notify the physician immediately. Compartment syndrome is a serious condition that requires urgent medical attention to prevent tissue damage and potential loss of limb. By notifying the physician right away, the nurse can ensure prompt evaluation and intervention, such as possible surgical fasciotomy, to relieve the pressure within the affected compartment. Option A, medicating with acetaminophen, would not address the underlying issue of compartment syndrome and could delay necessary medical intervention. Option C, releasing the traction, is not appropriate as it could exacerbate the compartment syndrome by further compromising blood flow. Option D, monitoring every 5 minutes, is not sufficient in this critical situation where immediate medical action is required. Educationally, this scenario highlights the importance of recognizing and responding to emergent conditions promptly in pediatric patients. Nurses must be vigilant in assessing for signs of complications like compartment syndrome and understand the urgency of involving the healthcare team swiftly to prevent adverse outcomes. This case emphasizes the prioritization of patient safety and the critical role of nurses in advocating for timely and appropriate care.
Question 2 of 5
The mother asks when the 'soft spots' close. The nurse explains that the neonate's anterior fontanel will normally close by age...
Correct Answer: C
Rationale: The correct answer is C) 12 to 18 months. The anterior fontanel, also known as the "soft spot," is the space where the skull bones have not yet fused in a newborn. It is important for the fontanel to remain open during infancy to allow for brain growth and development. The closure of the anterior fontanel typically occurs between 12 to 18 months of age. Option A) 2 to 3 months is incorrect because this is too early for the closure of the anterior fontanel. Option B) 6 to 8 months is also too early for the closure to occur. Option D) 20 to 24 months is too late for the closure of the fontanel, as it usually closes by 18 months. Educationally, understanding the timing of fontanel closure is crucial for pediatric nurses as it can indicate normal brain development. It is also important for nurses to educate parents about the normal growth and development milestones in infants to alleviate any concerns or misconceptions they may have. This knowledge helps nurses provide accurate information and support to parents as they care for their newborns.
Question 3 of 5
When instructing the mother about the neonate's need for sensory and visual stimulation, the nurse should plan to explain that the most highly developed sense in the neonate is...
Correct Answer: C
Rationale: In pediatric nursing, understanding the sensory development of neonates is crucial for providing appropriate care. The correct answer is C) Touch. Neonates have a well-developed sense of touch, which is the most highly developed sense at birth. This is important for bonding, comfort, and communication with the baby. Option A) Taste is not the most highly developed sense in neonates. While they can differentiate basic tastes, their taste buds are not as developed as their sense of touch. Option B) Smell is also developed but not as pronounced as touch. Option D) Hearing is important, but touch plays a more significant role in the initial bonding and comforting of the neonate. Educationally, it is vital for nurses to educate parents on the importance of touch in interacting with their newborn. Encouraging skin-to-skin contact, gentle massages, and responsive touch can promote bonding and overall well-being in neonates. Understanding sensory development helps parents create a nurturing environment for their baby, leading to better outcomes in terms of growth and development.
Question 4 of 5
The nurse teaches the client's mother about the normal reaction that the infant might experience 12 to 24 hours after the DPT immunization. Which of the following reactions would the nurse discuss?
Correct Answer: B
Rationale: The correct answer is B) Mild fever. After a DPT immunization, infants may experience a mild fever as a normal reaction 12 to 24 hours post-vaccination. This is an expected response to the vaccine and typically resolves on its own without causing harm. Option A) Lethargy is incorrect because while some infants may experience mild discomfort or irritability post-vaccination, significant lethargy would not be a typical or expected reaction. Option C) Diarrhea is incorrect as it is not a common reaction to the DPT vaccine in infants. Diarrhea post-vaccination would not be considered a normal response. Option D) Nasal congestion is also incorrect as it is not a typical reaction to the DPT vaccine. Nasal congestion is not a common side effect associated with this particular immunization. Educationally, understanding the expected reactions to vaccines is crucial for nurses and caregivers to provide appropriate care and guidance to parents. By knowing what is normal, healthcare providers can help alleviate parental concerns and ensure the best outcomes for the child's health post-vaccination.
Question 5 of 5
A 2-1/2-year-old child is brought to the clinic by his father who explains that the child is afraid of the dark and says 'no' when asked to do something. The nurse would explain that the negativism demonstrated by toddlers is frequently an expression of...
Correct Answer: A
Rationale: The correct answer is A) Quest for autonomy. Toddlers around the age of 2-3 years often exhibit negativism as they strive to assert their independence and autonomy. This behavior is a normal part of their development as they start to realize they are separate individuals from their caregivers. By saying 'no' and displaying resistance, they are asserting their will and testing boundaries. Option B) Hyperactivity is incorrect because hyperactivity refers to excessive physical movement and restlessness, which is not described in the scenario provided. Option C) Separation anxiety is incorrect because while it is common in toddlers, it is usually characterized by distress when separated from primary caregivers, not necessarily by negativism or refusal to comply with requests. Option D) Sibling rivalry is incorrect as it pertains to competition or jealousy between siblings, which is not relevant to the behavior described in the scenario. Educationally, understanding normal toddler behavior is crucial for pediatric nurses as it helps them differentiate between typical developmental milestones and potential concerns. Recognizing that negativism can be a healthy sign of a child's growing autonomy allows nurses to provide appropriate guidance and support to both children and their families during this stage of development.