ATI RN
Nursing Care of Children ATI
1. The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?
- A. Repression
- B. Regression
- C. Rationalization
- D. Fantasy
Correct answer: B
Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.
2. What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid using alkaline-based soap.
- B. Bathe the infant with sterile water.
- C. Cleanse skin with a gentle alkaline-based soap and water.
- D. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
Correct answer: B
Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.
3. Two children are working on a puzzle together in the hospital playroom. Which type of play describes this activity?
- A. Solitary play
- B. Associative play
- C. Parallel play
- D. Cooperative play
Correct answer: D
Rationale: The correct answer is D, cooperative play. In cooperative play, children work together toward a common goal, such as completing a puzzle. Solitary play (A) is when a child plays alone, associative play (B) involves children playing together but without a common goal, and parallel play (C) is when children play alongside each other without direct interaction.
4. Which type of family should the nurse recognize when a mother, her children, and a stepfather live together?
- A. Traditional nuclear
- B. Blended
- C. Extended
- D. Binuclear
Correct answer: B
Rationale: A blended family consists of a couple and their children from this and all previous relationships, including stepfamilies.
5. The nurse is conducting a teaching session for parents on nutrition. Which characteristics of families should the nurse consider that can cause families to struggle in providing adequate nutrition? (Select all that apply.)
- A. Homelessness
- B. Lower income
- C. Migrant status
- D. All of the above
Correct answer: D
Rationale: Factors like homelessness, lower income, and migrant status can create barriers to providing adequate nutrition for children.
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