ATI LPN
ATI LPN Pediatrics II Questions
Extract:
Question 1 of 5
A nurse is assisting in the care of an infant whose guardian reports intermittent vomiting for several days. Which of the following actions should the nurse take? Select all that apply.
Correct Answer: B,C,E
Rationale: A. Measure the infant's head circumference. Measuring head circumference is a standard part of routine well-child exams and growth monitoring, but it is not directly relevant to the current diagnosis of hypertrophic pyloric stenosis. The immediate clinical focus is on the gastrointestinal symptoms and associated dehydration. B. Weigh the infant. Weighing the infant is crucial for monitoring weight loss and assessing hydration status. Infants with hypertrophic pyloric stenosis are at risk of dehydration and malnutrition due to frequent, forceful vomiting. Regular weight checks help in evaluating the effectiveness of treatment and the nutritional status of the infant. C. Monitor intake and output. Monitoring intake and output is vital in this scenario to assess the infant's hydration status and kidney function. Given the forceful vomiting, there's a high risk of dehydration, as indicated by the dry mucous membranes, depressed fontanel, and reduced urine output. Accurate measurement helps guide fluid replacement therapy. D. Offer small frequent feedings of thickened liquids. Offering feedings, even of thickened liquids, is inappropriate in this situation because the infant requires surgical intervention for pyloric stenosis. Continued feeding may exacerbate vomiting and dehydration. Instead, the infant should be kept NPO (nothing by mouth) to prepare for surgery and prevent further complications. E. Evaluate serum electrolyte levels: Infants with hypertrophic pyloric stenosis often develop electrolyte imbalances such as hypokalemia, hypochloremia, and metabolic alkalosis due to prolonged vomiting. Evaluating serum electrolytes is essential to identify and correct these imbalances, which are critical to stabilizing the infant before surgical intervention. F. Plan to administer a plain water enema. A plain water enema is not indicated and is inappropriate for treating hypertrophic pyloric stenosis. The issue is not related to bowel movements or lower gastrointestinal obstruction, but rather to the pyloric sphincter in the stomach, which requires surgical correction. G. Implement contact precautions. Contact precautions are typically used to prevent the spread of infectious diseases. Hypertrophic pyloric stenosis is not an infectious condition but a structural anomaly. Thus, there is no need for contact precautions in this context.
Question 2 of 5
A nurse is providing teaching to a school-age child who has a diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?
Correct Answer: A
Rationale: I should not take my regular insulin when I am sick.' Regular insulin should not be withheld during illness, as blood glucose levels can increase during times of stress or infection. This statement indicates the child needs further education on managing diabetes during illness. 'I will rotate injections sites within my abdominal area.' Rotating injection sites within a specific area helps to prevent lipodystrophy and ensures consistent absorption of insulin. This statement shows appropriate understanding. 'I will test my blood sugar before meals and at bedtime.' Frequent monitoring of blood glucose is essential in managing type 1 diabetes. This statement indicates correct knowledge of monitoring practices. 'I should eat a snack before I play soccer.' Eating a snack before physical activity helps to prevent hypoglycemia. This statement indicates a proper understanding of diabetes management related to exercise.
Question 3 of 5
A nurse is collecting data from a child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Constipation: Vaso-occlusive crisis in sickle-cell disease is characterized by severe pain due to ischemia from blocked blood flow, rather than gastrointestinal symptoms like constipation. Vomiting: Vomiting is not typically associated with vaso-occlusive crisis but may occur due to pain or other causes. Pain: Pain is the hallmark symptom of vaso-occlusive crisis in sickle-cell disease, caused by ischemia and tissue damage. Bradycardia: Bradycardia is not a typical finding in vaso-occlusive crisis; instead, tachycardia might be present due to pain or stress.
Question 4 of 5
The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a 'positive' head check for lice?
Correct Answer: B
Rationale: Maculopapular lesions behind the ears: Maculopapular lesions are not characteristic of head lice infestation. White sacs attached to the hair shafts in the occipital area: White sacs (nits) attached to hair shafts are characteristic of head lice infestation. White flaky particles throughout the entire scalp region: White flaky particles are more suggestive of dry scalp or dandruff, not head lice. Lesions in the scalp that extend to the hairline or neck: Lesions extending to the hairline or neck could indicate secondary infection but are not specific to head lice infestation.
Extract:
Nurses Notes
Physical Examination
Vital Signs
Diagnostic Results
Guardians report the child has had a decrease in activity for 2 weeks. Child has been reporting pain in the legs. Guardians state that their child has been napping longer than usual and appears tired throughout the day. Child has had cold symptoms that have been persistent with a fever and congestion for the past 10 days. Guardians have been administering acetaminophen for fever with moderate relief
Question 5 of 5
A nurse is assisting in the care of an adolescent who reports abdominal pain. Complete the following sentence by using the list of options. The nurse should first address the client's ___ followed by the client's ___
Correct Answer: A,F
Rationale: The nurse should first address the client's Pain followed by the client's heart rate. Pain: Priority: Pain is a critical factor that needs immediate attention, especially since the adolescent reports a high pain level of 9/10, which indicates severe discomfort. Unmanaged pain can lead to increased stress, anxiety, and potentially worsen the patient's condition. The adolescent is guarding the abdomen, which indicates severe pain possibly due to an underlying issue such as appendicitis or another serious abdominal pathology. The right lower quadrant pain and positive obturator sign suggest an acute abdomen, which could be life-threatening and requires urgent attention. Heart rate: Priority: After addressing pain, the nurse should focus on the heart rate, which is elevated at 124 beats per minute (tachycardia). Tachycardia in this context could be a response to pain or an indication of infection, dehydration, or another serious underlying condition. Given that the temperature is slightly elevated (38°C or 100.4°F), there is a possibility of an infectious process, which could be contributing to both pain and the elevated heart rate.