during a routine health assessment the nurse notes that an 8 month old infant has a significant head lag which is the most appropriate action
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

2. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

3. Which parameter correlates best with measurements of total muscle mass?

Correct answer: D

Rationale: Upper arm circumference correlates best with total muscle mass because it includes both muscle and fat components, making it a reliable indicator of muscle mass.

4. The nurse is discussing sexually transmitted infections (STIs) with a 17-year-old student. Which cognitive development theory should the teaching plan be based on?

Correct answer: C

Rationale: The correct answer is C: 'Abstract thinking.' According to Piaget’s theory of cognitive development, adolescents, typically around the age of 12 and older, enter the formal operational stage where they can think abstractly and reason about hypothetical situations. When discussing complex topics like STIs with a 17-year-old student, it is essential to base the teaching plan on abstract thinking. Choice A, 'Sensorimotor reactions,' is incorrect as it pertains to the earliest stage in Piaget's theory (birth to 2 years old) focusing on sensory experiences and physical interactions. Choice B, 'Limited cause and effect understanding,' does not align with the cognitive abilities of a 17-year-old who is capable of more advanced thinking. Choice D, 'Concrete thinking,' is also incorrect as it refers to the stage before formal operations, where individuals think more concretely and struggle with abstract concepts.

5. Which disease requires strict isolation due to its mode of transmission?

Correct answer: B

Rationale: The correct answer is Chickenpox (choice B). Chickenpox is highly communicable and requires strict isolation to prevent the spread of the virus through direct contact, droplet transmission, and contaminated objects. Mumps (choice A) is also contagious but does not typically require strict isolation. Exanthema subitum (roseola) (choice C) and Erythema infectiosum (fifth disease) (choice D) are not as highly contagious as chickenpox and do not necessitate strict isolation.

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