ATI RN
ATI RN Pediatric Nursing 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is evaluating the pain level of a toddler who is cognitively impaired to a nonpharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?
Correct Answer: C
Rationale: The correct answer is C: FLACC. FLACC stands for Face, Legs, Activity, Cry, and Consolability and is a pain assessment tool specifically designed for nonverbal or cognitively impaired individuals like toddlers. The tool assesses the toddler's facial expressions, leg movements, activity level, crying, and ability to be consoled. This comprehensive evaluation helps the nurse accurately determine the toddler's pain level. Visual analog scale (
A) and FACES scale (
B) require the ability to communicate and understand abstract concepts, making them unsuitable for cognitively impaired toddlers. CRIES scale (
D) is primarily used for infants and may not be as effective for toddlers.
Question 2 of 5
A nurse is providing discharge teaching to the parents of a school-age child following surgery and cast application to the right forearm. Which of the following information is the priority for the nurse to include?
Correct Answer: C
Rationale: The correct answer is C: Monitor for pallor or swelling in the child's affected hand. This is the priority information because it can indicate complications such as impaired circulation or compartment syndrome, which require immediate medical attention to prevent permanent damage. Skin irritation at the cast edges (choice
A) can be addressed with padding adjustments but is not as urgent. Restricting strenuous activities (choice
B) is important but not the priority. Using a hair dryer on cool setting to relieve itching (choice
D) can cause burns and should be avoided.
Question 3 of 5
A nurse is assessing a school-age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
Correct Answer: B
Rationale: The correct answer is B: A decrease in peripheral edema. Furosemide is a diuretic that helps the body eliminate excess fluid and sodium, reducing fluid overload and edema in heart failure. Monitoring peripheral edema is crucial as a decrease indicates that the medication is effectively reducing fluid retention.
A: An increase in potassium levels is a potential side effect of furosemide due to potassium loss with diuresis.
C: A decrease in cardiac output would be an adverse effect of heart failure worsening, not an indication of furosemide effectiveness.
D: An increase in venous pressure would suggest worsening heart failure and ineffective furosemide therapy.
Question 4 of 5
A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Your child should walk the bicycle through intersections. This instruction is important for bicycle safety as walking the bicycle through intersections allows the child to be more visible to drivers and reduces the risk of accidents. Riding against traffic (choice
A) is dangerous as it goes against traffic laws and increases the likelihood of collisions. Keeping the bicycle 3 feet from the curb (choice
B) is incorrect as it can put the child in the path of vehicles. Ensuring the child's feet are 3 to 6 inches off the ground (choice
D) is not a safety instruction related to bicycle riding.
Question 5 of 5
A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?
Correct Answer: B
Rationale: The correct answer is B: Doll's eye reflex intact. This reflex, also known as oculocephalic reflex, should not be present in infants beyond 3 months old. It involves the eyes moving in the opposite direction of head movement, which is abnormal in older infants. This finding could indicate a neurological issue and should be reported to the provider for further evaluation.
Choice A is normal as lack of head lag at 4 months indicates appropriate muscle tone.
Choice C is normal as infants should start producing tears when crying around this age.
Choice D is normal in infants under 2 years old as the Babinski reflex is present until this age.