the child is admitted to the hospital unit newly diagnosed with retinoblastoma which clinical manifestation does the nurse anticipate upon assessment
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment?

Correct answer: A

Rationale: The correct answer is A: A white reflex. The 'white reflex' or leukocoria is a common sign of retinoblastoma. It occurs when the light reflects off the tumor in the eye, giving the pupil a white appearance instead of the normal red reflex. Blue-tinged sclerae (choice B) and yellow-tinged sclerae (choice D) are not typical manifestations of retinoblastoma. A red reflex (choice C) is the normal reflection seen in the eye when light is shone on it and is not associated with retinoblastoma.

2. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

3. What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?

Correct answer: C

Rationale: Pure tone audiometry is an appropriate and effective screening test for hearing in a 5-year-old child, helping to assess the ability to hear various frequencies and volumes.

4. With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?

Correct answer: C

Rationale: A BMI-for-age at the 85th percentile indicates a child is at risk for being overweight, according to the National Center for Health Statistics criteria.

5. Which best describes signs and symptoms as part of a nursing diagnosis?

Correct answer: D

Rationale: Signs and symptoms are cues and clusters derived from patient assessments that are used to form a nursing diagnosis, guiding the development of a care plan.

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