a nurse is caring for a 10 year old child following a head injury which of the following findings should the nurse identify as an indication that the

ATI RN

ATI Pediatric Proctored Exam 2023

1. A child is being cared for following a head injury. Which of the following findings should indicate to the healthcare provider that the child is developing diabetes insipidus?

A. Urine specific gravity of 1.045
B. Sodium level of 155
C. Blood glucose level of 45
D. Urine output of 35 ml per hour

Correct answer: B

Rationale: In a child with a head injury, the development of diabetes insipidus can occur due to pituitary hypofunction, leading to a deficiency of antidiuretic hormone. An elevated sodium level (hypernatremia) is a key finding in diabetes insipidus due to the excessive loss of free water in the urine, resulting in increased sodium concentration in the blood.

2. What does a Z-score of -3.00 indicate?

A. The child's score indicates he is ahead of his peers and performing well
B. The child's score places him within normal limits on this test item
C. The test is inconclusive
D. The child's score falls below the majority of his peers on this test

Correct answer: D

Rationale: A Z-score of -3.00 indicates that the child's performance is significantly below the average of their peers. It represents an extreme low score, indicating a substantial deviation from the mean performance of the group.

3. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

A. Position the infant on his abdomen
B. Cleanse the incision site with hydrogen peroxide
C. Offer the infant a pacifier
D. Keep the infant's elbow restrained

Correct answer: D

Rationale:

4. Which statement is not part of the developmental care approach?

A. Family-centered care
B. Care on a sliding payment scale
C. Healing environment
D. Protected sleep

Correct answer: B

Rationale: The developmental care approach emphasizes creating an environment that supports the infant's developmental needs, including family-centered care, a healing environment, and promoting protected sleep. Payment scale considerations are not a component of developmental care.

5. The nurse plans to closely monitor for which clinical manifestation after administering furosemide (Lasix)?

A. Decrease pulse
B. Decrease temperature
C. Decrease BP
D. Decrease respiratory rate.

Correct answer: C

Rationale: High-ceiling diuretics, such as furosemide, are the most effective diuretic agents. They produce more loss of fluid and electrolytes than any others. A sudden loss of fluid can result in decreased BP. When BP drops, the pulse will probably increase rather than decrease.