ATI LPN
ATI LPN Pediatrics II Questions
Extract:
Question 1 of 5
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Initiate isotonic fluids with 20 mEq/L potassium chloride. The priority in treating acute gastroenteritis in a toddler is to manage dehydration, which is often severe due to fluid loss from vomiting and diarrhea. Isotonic fluids with electrolytes like potassium chloride help to restore fluid balance and prevent complications like electrolyte imbalances. This is the most urgent action to stabilize the child's condition. Request evaluation of the toddler's serum electrolytes. While important, this can be done after fluid resuscitation has begun to assess the severity of electrolyte imbalances. Determine if the toddler is voiding. Important for assessing renal function, but not the first priority in acute gastroenteritis. Collect a stool sample from the toddler. Useful for identifying the causative organism but not as urgent as fluid resuscitation.
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 2 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.
Extract:
Question 3 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 4 of 5
A nurse is assisting in the care of a toddler. Complete the following sentence by using the list of options. The nurse should first address the child's ___ followed by the child's ___
| pain |
| bruising |
| temperature |
| heart rate |
| laboratory values |
| respiratory rate |
| nasal stuffiness |
Correct Answer: C,E
Rationale: The nurse should first address the child's temperature followed by the child's laboratory values. Temperature: The child has a fever of 38.9°C (102°F), which is above the normal range for toddlers (36.5°C to 37.5°C or 97.7°F to 99.5°F). A high fever can indicate an ongoing infection or inflammatory process and can lead to serious complications, especially in a toddler. Addressing the fever promptly is crucial to prevent potential febrile seizures, dehydration, and other heat-related complications. Fever management is essential to improving the child's comfort and preventing the worsening of symptoms. Laboratory values: The child's laboratory results show abnormalities that are significant. Hemoglobin is low at 7.6 g/dL (indicating anemia), hematocrit is also low at 21%, and platelets are decreased at 110,000/mm³, which could suggest a hematologic disorder such as leukemia or a severe infection. The elevated white blood cell count further supports the presence of an infection or an inflammatory response. These lab abnormalities are critical and need to be addressed to determine the underlying cause and to plan further treatment.
Extract:
Question 5 of 5
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
Correct Answer: D
Rationale: Maintain a saline-lock. Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease. Educate the parents about potential complications. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness. Place the child on a no-salt-added diet. A no-salt-added diet is important to help manage fluid retention and hypertension, which are common in acute glomerulonephritis. However, while important, it does not take immediate priority over assessing the child's fluid status. Check the child's weight daily. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.