ATI RN
RN Nursing Care of Children 2019 With NGN
1. Parents would suspect hearing loss if their child did not:
- A. Turn away from a sound
- B. Startle with sudden loud noises immediately after birth
- C. Talk at 4 months
- D. Babble at 2 months
Correct answer: D
Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.
2. What problem is most often associated with myelomeningocele?
- A. Biliary atresia
- B. Hydrocephalus
- C. Craniostenosis
- D. Tracheoesophageal fistula
Correct answer: B
Rationale: Hydrocephalus is the most commonly associated problem with myelomeningocele, present in 80% to 90% of affected children. Biliary atresia and tracheoesophageal fistula are not typically associated with myelomeningocele. Craniostenosis refers to the premature closing of cranial sutures and is not a common issue seen with myelomeningocele.
3. What intervention is crucial during a sickle cell crisis in a child?
- A. Administer oxygen
- B. Apply cold compresses
- C. Restrict fluids
- D. Encourage bed rest
Correct answer: A
Rationale: Administering oxygen is crucial during a sickle cell crisis in a child as it helps to prevent further sickling of cells. Oxygen therapy can improve oxygen saturation levels, reducing the risk of tissue damage and complications. Applying cold compresses (choice B) is not recommended as it can potentially worsen vaso-occlusive crisis by causing vasoconstriction. Restricting fluids (choice C) is not appropriate as hydration is essential to prevent dehydration and maintain adequate blood flow. Encouraging bed rest (choice D) may be necessary but administering oxygen takes precedence in managing a sickle cell crisis.
4. During which phase of the nursing process does the nurse use essential information about the child’s physical, social, and emotional health to decide which interventions to use?
- A. Implementation
- B. Planning
- C. Diagnosis
- D. Assessment
Correct answer: B
Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse utilizes essential information gathered during the assessment about the child’s physical, social, and emotional health to determine the most appropriate interventions to address the identified needs. This phase focuses on developing a comprehensive care plan tailored to the individual child. A) Implementation is incorrect because this phase involves carrying out the interventions outlined in the care plan. C) Diagnosis is incorrect as it refers to identifying health issues based on the assessment data. D) Assessment is incorrect as it involves collecting and analyzing data about the child's health status, rather than deciding on interventions.
5. What approach is the most appropriate when performing a physical assessment on a toddler?
- A. Demonstrate the use of equipment
- B. Perform traumatic procedures last
- C. Use minimum physical contact initially
- D. Always proceed systematically in a head-to-toe direction
Correct answer: C
Rationale: The most appropriate approach when performing a physical assessment on a toddler is to use minimum physical contact initially. This helps gain the toddler's cooperation and reduces their distress. Performing traumatic procedures last is crucial as they are likely to upset the child and should be handled with care. Demonstrating the use of equipment may be complex for toddlers to understand, so it is not the most appropriate initial approach. Proceeding systematically in a head-to-toe direction is a good practice but using minimum physical contact initially is more important to establish trust and cooperation with the toddler.
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