ATI RN
RN Nursing Care of Children 2019 With NGN
1. A child is refusing to use the potty and having accidents, even though he has achieved toilet training. This is an example of which type of behavior?
- A. Positive reinforcement
- B. Desensitization
- C. Phobia
- D. Regression
Correct answer: D
Rationale: The correct answer is D, regression. Regression occurs when a child reverts to an earlier behavior, such as having accidents after being successfully toilet trained. This regression often happens due to stress or changes in routine. Choices A, B, and C are incorrect because positive reinforcement involves encouraging desired behavior, desensitization is a process of reducing sensitivity to a stimulus, and phobia is an intense fear or aversion to a specific object or situation, none of which directly apply to the described situation of the child having accidents after being toilet trained.
2. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
- A. Feet and hands
- B. Bridge of nose
- C. Circumoral area
- D. Mucous membranes
Correct answer: A
Rationale: Nonpathologic cyanosis in newborns shortly after birth is typically present in the feet and hands, known as acrocyanosis. This is a normal finding due to the immature peripheral circulation in newborns. Cyanosis of the bridge of the nose, circumoral area, and mucous membranes indicates generalized cyanosis, which suggests a potential underlying distress or major abnormality. Therefore, choice A is correct as it describes the expected location for nonpathologic cyanosis in newborns, while choices B, C, and D represent areas associated with abnormal cyanosis.
3. Which is usually the only symptom of pediculosis capitis (head lice)?
- A. Itching
- B. Vesicles
- C. Scalp rash
- D. Localized inflammatory response
Correct answer: A
Rationale: Itching is typically the primary and most common symptom of pediculosis capitis due to the lice bites on the scalp.
4. What is the recommended position for a child after a tonsillectomy?
- A. Supine
- B. Prone
- C. Side-lying
- D. Fowler's position
Correct answer: C
Rationale: The correct answer is C: Side-lying. The side-lying position is recommended after a tonsillectomy to facilitate drainage of secretions and reduce the risk of aspiration. This position helps prevent blood from pooling in the back of the throat, decreasing the chance of bleeding postoperatively. Supine (lying face up), while commonly used in other situations, may not be ideal immediately after a tonsillectomy due to the risk of airway obstruction from blood clots. Prone (lying face down) is not recommended as it can hinder breathing and increase the risk of complications. Fowler's position (semi-sitting) is also not typically used after a tonsillectomy because it may cause discomfort and hinder proper drainage.
5. The nurse is teaching parents guidelines for feeding their 8-month-old infant with failure to thrive (FTT). Which statement by the parents indicates a need for further teaching?
- A. We will continue to use the 24-kcal/oz formula.
- B. We will be sure to follow the formula preparation instructions.
- C. We will be sure to give our infant at least 8 oz of juice every day.
- D. We will be sure to feed our infant according to the written schedule.
Correct answer: C
Rationale: Providing 8 oz of juice daily is excessive for an 8-month-old infant and can displace other nutrient-rich foods or formulas that are necessary for growth, especially in an infant with FTT.
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