ATI RN
Nursing Care of Children ATI
1. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose test.” What is the purpose of this test?
- A. Deep tendon reflexes
- B. Cerebellar function
- C. Sensory discrimination
- D. Ability to follow directions
Correct answer: B
Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.
2. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?
- A. Palpate another area simultaneously
- B. Ask the child not to laugh or move
- C. Begin with deeper palpation and gradually progress to superficial palpation
- D. Have the child help with palpation by placing his or her hand over the palpating hand
Correct answer: D
Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.
3. At what stage can infants raise their heads and gain control of their trunks before walking due to which directional pattern of development?
- A. Cephalocaudal
- B. Anterior to posterior
- C. Proximodistal
- D. Normal growth curve charts
Correct answer: A
Rationale: The correct answer is A: Cephalocaudal. The cephalocaudal pattern of development means that growth and motor control proceed from the head downward through the body. This explains why infants can raise their heads before they can sit and gain control of their trunks before walking. Choices B, C, and D are incorrect. Anterior to posterior refers to development from the front to the back, while proximodistal refers to development from the center of the body outward. Normal growth curve charts are used to track physical growth over time and are not directly related to the directional pattern of development in infants.
4. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?
- A. Encourage the child to blow the nose gently
- B. Notify the physician if mucus is observed in the emesis
- C. Position the child supine in the immediate postoperative period
- D. Avoid giving citrus juice
Correct answer: D
Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.
5. How is masturbation in the pre-school child viewed?
- A. Abnormal behavior that needs to be dealt with immediately
- B. Disruptive to the family
- C. Normal behavior that can best be dealt with by ignoring and providing distraction
- D. Embarrassing to the parents
Correct answer: C
Rationale: Masturbation in preschool children is a normal behavior as they explore their bodies. It is best viewed as a natural part of development. Parents are often advised to ignore it and provide distractions rather than making the child feel ashamed or embarrassed. Choice A is incorrect because it is a natural behavior and not considered abnormal in this context. Choice B is incorrect as it does not necessarily disrupt the family. Choice D is incorrect as the focus should be on the child's development and well-being, not on the parents' feelings of embarrassment.
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