ATI RN
ATI Nursing Care of Children 2019 B
1. What disease should be suspected in a 3-day-old infant presenting with abdominal distention, vomiting, and failure to pass meconium?
- A. Pyloric stenosis
- B. Intussusception
- C. Hirschsprung disease
- D. Celiac disease
Correct answer: C
Rationale: Hirschsprung disease should be suspected in a newborn with abdominal distention, vomiting, and failure to pass meconium. This condition arises from a congenital absence of nerve cells in a portion of the colon, leading to severe constipation and intestinal obstruction. Pyloric stenosis typically presents with non-bilious projectile vomiting in the first few weeks of life. Intussusception classically manifests with sudden onset of colicky abdominal pain and currant jelly stools. Celiac disease may present with chronic diarrhea, failure to thrive, and abdominal distention but is less likely in this scenario.
2. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)
- A. Reassessments
- B. Nursing care provided
- C. Initial assessments
- D. All of the above
Correct answer: D
Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.
3. What statement best describes Hirschsprung disease?
- A. The colon has an aganglionic segment.
- B. It results in frequent evacuation of solids, liquid, and gas.
- C. The neonate passes excessive amounts of meconium.
- D. It results in excessive peristaltic movements within the gastrointestinal tract.
Correct answer: A
Rationale: Hirschsprung disease is characterized by the absence of ganglion cells in a segment of the colon, leading to a lack of peristalsis and obstruction. The other options do not accurately describe this condition.
4. The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?
- A. History
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct answer: A
Rationale: The history section of the health record includes details about pregnancy, labor, and delivery, as these factors can have significant implications for the child's health.
5. Examination of the abdomen is performed correctly by the nurse in which order?
- A. Inspection, palpation, percussion, and auscultation
- B. Inspection, percussion, auscultation, and palpation
- C. Palpation, percussion, auscultation, and inspection
- D. Inspection, auscultation, percussion, and palpation
Correct answer: D
Rationale: The correct order for abdominal examination is inspection, auscult
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