ATI RN
ATI RN Pediatric Nursing 2023 I Questions
Extract:
A 15-year-old adolescent is admitted for a vaso-occlusive crisis. The parent reports that the adolescent has a low-grade fever and has vomited for 3 days. The adolescent reports having right-sided and low back pain. They also report hands and right knee are painful and swollen. The client reports pain as 8 on a scale of 0 to 10. Vital Signs: Temperature 37.8° C (100° F), Heart rate 100/min, Blood pressure 110/72 mm Hg, Respiratory rate 20/min, Oxygen saturation 95% on room air. Assessment: Awake, alert, and oriented x 3, Yellow sclera of eyes noted bilaterally, Right upper quadrant tender to palpation, Hands painful to touch and swollen bilaterally, Right knee is swollen, warm to palpation, and the client reports pain as 8 on a scale of 0 to 10, Client is tearful and grimacing during the examination.
Question 1 of 5
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
Correct Answer: A,B,C,F
Rationale: The correct interventions are A, B, C, and F. A: Ensuring the pneumococcal vaccine is current helps prevent infections. B: Administering folic acid as prescribed supports the adolescent's growth and development. C: Monitoring oxygen saturation is crucial for detecting respiratory issues in adolescents. F: Administering meperidine IV for pain management is appropriate. Incorrect choices: D: Placing the client on strict bed rest may lead to deconditioning and complications. E: Applying cold compresses may not be appropriate for all conditions and could worsen inflammation. G: Restricting oral intake is not necessary unless there are specific medical indications.
Extract:
Infant was full-term at birth. Birth weight was 3.5 kg (7.7 lb). Infant is not gaining weight as expected. One week ago at outpatient visit, weight was 3.6 kg (7.9 lb). Parent reports for past 2 days infant is breathing faster during feedings and does not finish feedings. Parent also reports decreased appetite and puffiness around the infant's eyes. Parent states that the last wet diaper was about 10 hr ago. Infant admitted for diagnostic evaluation, failure to thrive, and nutritional/fluid support. Vital Signs Admission: Temperature 37.7° C (99.9° F), Heart rate 174/min while sleeping, Respiratory rate 72/min while sleeping. Assessment: Respirations: Tachypneic with moderate retractions and nasal flaring. Upon auscultation, crackles heard in all lung fields. No nasal drainage noted. Dry cough noted periodically. Skin: Pallor, scalp is diaphoretic, lower extremities are cool to touch. Cardiac: Tachycardic, regular rhythm, no murmur is heard. Peripheral pulses are full and bounding in the upper extremities and weak bilateral pedal pulses are noted. Fluids: Mucous membranes are slightly dry and pink. Skin turgor is slightly decreased. Capillary refill is 3 seconds. Noted periorbital edema and nonpitting edema of feet. Anterior fontanel is soft and slightly depressed. Diaper remains dry. Abdomen: Soft, full, round, bowel sounds are present and active. Blood pressure in right upper extremity 60/39 mm Hg, Oxygen saturation 90%. Laboratory Results: Chest x-ray: mild left ventricular hypertrophy is noted. Increased pulmonary vascular markings are noted in all lobes.
Question 2 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: C (Condition), A,B (Actions), B,C (Parameters)
Rationale: Action to Take: Provide chest physiotherapy and postural drainage, Elevate the head of the bed to a 45° angle; Potential Condition: Respiratory syncytial virus bronchiolitis; Parameter to Monitor: Intake and output, Respiratory status.
Rationale: For a client most likely experiencing respiratory syncytial virus bronchiolitis, the nurse should provide chest physiotherapy and postural drainage to help clear secretions and elevate the head of the bed to improve breathing. Monitoring intake and output helps assess hydration status, and monitoring respiratory status is crucial in evaluating the client's response to treatment and progression of the condition.
Incorrect choices: A includes conditions unrelated to the client's symptoms. B involves actions for different conditions and medications. C includes parameters not directly related to the potential condition.
Extract:
Question 3 of 5
A nurse is performing a cranial nerve assessment on a school-age child. Which of the following findings indicates proper functioning of the child's trigeminal nerve?
Correct Answer: D
Rationale: The correct answer is D. Proper functioning of the trigeminal nerve involves the sensation of the face and motor function of the jaw. When the child has symmetrical jaw strength when biting down, it indicates that the trigeminal nerve is functioning correctly. A is incorrect as it assesses the vestibular system, B assesses the glossopharyngeal nerve, and C assesses the olfactory nerve.
Question 4 of 5
A nurse is assessing a school-age child who is receiving cefazolin. For which of the following adverse effects should the nurse monitor?
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. Cefazolin is associated with severe skin reactions like Stevens-Johnson syndrome, a rare but serious condition characterized by blistering and peeling of the skin. The nurse should monitor for symptoms such as rash, blistering, mucosal involvement, and fever. Hypotension, prolonged wound healing, and bradypnea are not commonly associated adverse effects of cefazolin. Hypotension may be more common with other antibiotics like vancomycin. Prolonged wound healing is not a typical adverse effect of cefazolin but could occur in the context of an infection that is not being adequately treated. Bradypnea is not a known adverse effect of cefazolin.
Question 5 of 5
A nurse is caring for an adolescent who has a new diagnosis of type 1 diabetes mellitus. Which of the following recommendations should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: Consult with a nutritionist. This is important for a newly diagnosed adolescent with type 1 diabetes mellitus to learn about proper dietary management. A nutritionist can help create a meal plan that considers the adolescent's specific needs, ensuring they understand how food affects blood sugar levels. Option A is incorrect because opened vials of insulin should be stored according to the manufacturer's instructions. Option B is not directly related to managing diabetes. Option D is important but does not address the initial education needed for dietary management.