the nurse is assessing a 3 year old child which assessment finding would the nurse identify as abnormal
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?

Correct answer: C

Rationale: The correct answer is C. Falling when bending over to touch toes could indicate a developmental delay or a balance issue that may need further assessment. Choices A, B, and D are typical developmental milestones for a 3-year-old child. Pedaling a tricycle without assistance, unscrewing a bolt on a toy, and building a tower of 10 cubes are all age-appropriate activities for a child of this age.

2. The nurse is teaching parents about the effects of media on childhood obesity. The nurse realizes the parents understand the teaching if they make which statements? (Select all that apply.)

Correct answer: D

Rationale: Increased screen time is associated with unhealthy habits, such as poor sleep and snacking, which contribute to obesity, but it does not necessarily improve nutrition knowledge.

3. A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?

Correct answer: B

Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.

4. 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.

5. What is the primary treatment goal for a child with nephrotic syndrome?

Correct answer: A

Rationale: The correct answer is A: Reduce proteinuria. In nephrotic syndrome, the primary treatment goal is to reduce proteinuria to prevent further kidney damage. Lowering blood pressure (choice B) is important in managing some types of kidney disease but is not the primary treatment goal in nephrotic syndrome. Increasing urine output (choice C) and preventing infections (choice D) are important aspects of supportive care but are not the primary treatment goal for nephrotic syndrome.

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