ATI RN
Nursing Care of Children ATI
1. A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?
- A. Monitor blood pressure every 30 minutes.
- B. Reposition the child every two hours.
- C. Limit visitors.
- D. Encourage fluids.
Correct answer: B
Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.
2. The nurse is preparing to admit a 10-year-old child with appendicitis. What clinical manifestations should the nurse expect to observe?
- A. Fever
- B. Vomiting
- C. Tachycardia
- D. All of the above
Correct answer: D
Rationale: Correct! Typical signs of appendicitis include fever, vomiting, and tachycardia due to infection and inflammation. These clinical manifestations are commonly observed in patients with appendicitis. Hyperactive bowel sounds are not typically associated with appendicitis, so they are not expected findings in this situation. Therefore, the correct answer is 'All of the above.'
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. A child has a planned hospitalization in a few weeks, and the client and family appear very stressed. Which nursing action will minimize their stress?
- A. Telling the client and family that everything will be fine
- B. Explaining how the child will benefit from the surgery
- C. Telling the client and family that the surgeon is very good
- D. Giving a tour of the hospital unit or surgical area
Correct answer: D
Rationale: The correct nursing action to minimize the stress of the child and family is giving a tour of the hospital unit or surgical area. Familiarizing them with the hospital environment can help reduce their anxiety by allowing them to see where the child will be staying and the surroundings. Choices A, B, and C do not directly address the need to reduce stress by providing a tangible way to alleviate anxiety through exposure to the hospital setting.
5. Physiologically, the child compensates for fluid volume losses by which mechanism?
- A. Inhibition of aldosterone secretion
- B. Hemoconcentration to reduce cardiac workload
- C. Fluid shift from interstitial space to intravascular space
- D. Vasodilation of peripheral arterioles to increase perfusion
Correct answer: C
Rationale: In response to dehydration, the body compensates by shifting fluids from the interstitial spaces to the intravascular space to maintain blood pressure and perfusion to vital organs. Hemoconcentration and vasoconstriction are other compensatory mechanisms but are less immediate.
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