an infant has been diagnosed with failure to thrive ftt classified according to the pathophysiology of defective utilization the nurse understands tha
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Nursing Elites

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Nursing Care of Children ATI

1. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what?

Correct answer: C

Rationale: FTT classified as defective utilization is often related to conditions like congenital infections, which interfere with the body's ability to effectively use nutrients. Conditions like cystic fibrosis and hyperthyroidism can also contribute to FTT but are categorized differently

2. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?

Correct answer: D

Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.

3. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

4. Where in the health history does a record of immunizations belong?

Correct answer: A

Rationale: Immunizations are part of the patient’s health history and are recorded under the history section to ensure the child is up-to-date with vaccinations.

5. What self-report pain rating scales can be used in children as young as 3 years of age?

Correct answer: C

Rationale: The FACES Pain Rating Scale is suitable for children as young as 3 years of age. It uses facial expressions to depict different levels of pain, making it easy for young children to understand and use. The Poker Chip Tool is validated for children aged 4 and older who have a certain level of cognitive ability. The Visual Analog Scale is more appropriate for children aged 7 and above. The Word-Graphic Rating Scale, which uses descriptive words, is recommended for children in the age range of 4 to 17 years.

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