ATI RN Pediatric Nursing 2023 I | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Bruising around the wrists. This finding is a potential indicator of physical abuse because bruising around the wrists may suggest that the child has been forcefully grabbed or restrained. Bruises in areas not typically injured during normal play or accidents can be a red flag for abuse. Bruising on the wrists can also indicate defensive injuries. The other choices are less likely to be indicators of physical abuse. A missing front deciduous tooth (
A) is a common occurrence in children due to natural tooth loss. Weight in the 45th percentile (
B) is within the normal range and does not indicate abuse. Abrasions on the knees (
D) are common in active children and are usually not suggestive of abuse.

Correct Answer: B

Rationale: The correct answer is B: Provide a pacifier coated with an oral sucrose solution prior to the injections. This is appropriate as it helps to reduce pain and distress during the immunizations for the infant. The pacifier with sucrose solution can provide comfort and distraction, leading to a more positive experience.
Choice A (EMLA cream) may reduce pain but is not as effective for infants.
Choice C (deltoid muscle) is not recommended for infants.
Choice D (20-gauge needle) is too large for an infant and may cause more pain.

Correct Answer: D

Rationale: The correct answer is D: Maculopapular skin burrows on the hand. Scabies is caused by the Sarcoptes scabiei mite burrowing into the skin, leading to the characteristic burrows. These burrows often appear as tiny, raised, serpiginous lines on the hands, wrists, and interdigital spaces. The other choices are incorrect as scaly lesions on the inner thighs (
A) are more suggestive of eczema or psoriasis, a rash with red macular lesions on the scalp (
B) is more indicative of conditions like seborrheic dermatitis or fungal infections, and a bull's eye edematous area on the groin (
C) is more characteristic of conditions like Lyme disease.
Therefore, the presence of maculopapular skin burrows on the hand is the key manifestation of scabies.

Correct Answer: A

Rationale: The correct answer is A. Asking the client if he is considering harming himself is the priority as it assesses the immediate risk of self-harm, which is crucial in managing major depressive disorder. This action allows the nurse to evaluate the severity of the client's condition and initiate appropriate interventions to ensure the client's safety. Encouraging group therapy (
B) and administering antidepressants (
C) are important, but assessing for self-harm takes precedence. Assisting with ADLs (
D) is also important but not as urgent as assessing for self-harm.

Correct Answer: C

Rationale: The correct answer is C. The nurse should assess the adolescent with sickle cell anemia and slurred speech first as this can indicate a potential neurological complication such as a stroke. Neurological changes require immediate assessment and intervention to prevent further complications. Assessing and addressing the slurred speech is crucial in this situation. Option A involves a toddler with a new diagnosis of osteomyelitis, which is important but not as urgent as assessing neurological symptoms. Option B involves an adolescent in skin traction with pain, which can be managed after the urgent assessment of slurred speech. Option D involves a toddler with a burn injury, which also requires attention but is not as urgent as the potential neurological issue in option C.