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 planning an educational session for a group of 9-year-olds and their parents aimed at decreasing injuries and accidents among this age group. Which topics should be included in the educational session to accomplish the goal?
- A. Safety rules when dealing with fire to prevent burns.
- B. Safety rules when dealing with toxic substances to prevent poisonings.
- C. Pedestrian, motor vehicle, and bike safety rules.
- D. Safety information regarding the use of all-terrain vehicles (ATVs).
Correct answer: C
Rationale: For school-aged children, pedestrian, motor vehicle, and bike safety are critical areas to focus on as accidents involving these are common in this age group. Education about fire safety and toxic substances is also important, but the priority is on preventing accidents in everyday activities. Therefore, choices A, B, and D are not the most relevant for addressing the goal of decreasing injuries and accidents in this age group.
3. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?
- A. Hold feedings.
- B. Check gastric residuals before feedings.
- C. Take rectal temperature.
- D. Closely monitor abdominal distention.
Correct answer: D
Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.
4. The nurse is caring for a non-English-speaking child and family. Which should the nurse consider when using an interpreter?
- A. Pose several questions at a time
- B. Use medical jargon when possible
- C. Communicate directly with family members when asking questions
- D. Carry on some communication in English with the interpreter about the family's needs
Correct answer: C
Rationale: The nurse should communicate directly with the family members when asking questions, ensuring the interpreter translates accurately without adding or omitting information.
5. The Denver II is a test used to assess children. What does it evaluate?
- A. Behavior problems
- B. Developmental status
- C. Body mass index
- D. Infection likelihood
Correct answer: B
Rationale: The Denver II Developmental Screening Test is used to assess a child's development in four areas: personal-social, fine motor-adaptive, language, and gross motor skills. It helps identify children who may need further evaluation. Choice A, behavior problems, is incorrect as the Denver II primarily focuses on developmental milestones rather than behavior. Choice C, body mass index, is unrelated to the assessment of child development. Choice D, infection likelihood, is also not evaluated by the Denver II test.
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