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. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?
- A. Prone position
- B. Sterile water feedings
- C. Monitoring serum laboratory electrolytes
- D. Covering the defect with a sterile bowel bag
Correct answer: D
Rationale: The correct priority intervention for an infant with gastroschisis is to cover the exposed abdominal contents with a sterile bowel bag. This action helps protect the intestines from injury, contamination, and dehydration before surgical repair. Choice A, placing the infant in the prone position, is not appropriate as it does not address the immediate need to protect the exposed intestines. Choice B, sterile water feedings, and Choice C, monitoring serum laboratory electrolytes, are not the priority interventions for this condition. Sterile water feedings may not provide the necessary protection for the exposed intestines, and monitoring electrolytes, while important, is secondary to the immediate need for protection and hydration of the exposed abdominal contents.
3. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?
- A. Refer him for immediate medical evaluation
- B. Administer analgesics and recommend scrotal support.
- C. Apply an ice bag and observe for increasing pain.
- D. Reassure the adolescent that occasional pain is common with the changes of puberty.
Correct answer: A
Rationale: Sudden and severe scrotal pain in an adolescent male is a medical emergency and may indicate testicular torsion, which requires immediate evaluation and intervention to prevent testicular loss.
4. Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, while the other is stacking blocks. Which type of play is this?
- A. Cooperative play
- B. Solitary play
- C. Parallel play
- D. Associative play
Correct answer: C
Rationale: The correct answer is C, parallel play. Parallel play is observed when children play alongside each other but do not directly interact. In this scenario, each child is engaged in their own activity without engaging or influencing each other's play, which characterizes parallel play. Cooperative play (choice A) involves children playing together towards a common goal, which is not evident in the given situation. Solitary play (choice B) is when a child plays alone, unrelated to the presence of others. Associative play (choice D) involves more interaction and sharing of toys between children, which is not happening in the described play scenario.
5. Which type of play is most appropriate for a hospitalized toddler?
- A. Cooperative play
- B. Parallel play
- C. Competitive play
- D. Solitary play
Correct answer: B
Rationale: The most appropriate type of play for a hospitalized toddler is parallel play. This type of play allows toddlers to engage alongside each other but not directly with each other, which can be comforting and less overwhelming in a hospital setting. Cooperative play (choice A) involves working together towards a common goal, which may be challenging for a hospitalized toddler. Competitive play (choice C) involves a level of rivalry that may not be suitable during a hospital stay. Solitary play (choice D) involves playing alone, which may not provide the social interaction and distraction that parallel play can offer in a hospital environment.
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