ATI RN
ATI Nursing Care of Children 2019 B
1. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe?
- A. Steatorrhea
- B. Clay-colored
- C. Currant jelly-like
- D. Loose stools with undigested food
Correct answer: C
Rationale: Corrected Rationale: Currant jelly-like stools, which contain blood and mucus, are characteristic of Meckel diverticulum. This symptom occurs due to the bleeding from the ectopic gastric mucosa present in the diverticulum. Steatorrhea (choice A) is not typically associated with Meckel diverticulum. Clay-colored stools (choice B) are seen in conditions affecting the biliary system. Loose stools with undigested food (choice D) may indicate malabsorption issues, but it is not specifically linked to Meckel diverticulum.
2. The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
- A. All are correct
- B. Anorexia
- C. Hypertension
- D. Purpura
Correct answer: A
Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.
3. The nurse is teaching a parent with a 2-month-old infant who has been diagnosed with colic about ways to relieve colic. Which statement by the parent indicates the need for additional teaching?
- A. I should let my infant cry for at least 30 minutes before I respond.
- B. I will swaddle my infant tightly with a soft blanket.
- C. I should massage my infant's abdomen whenever possible.
- D. I will place my infant in an upright seat after feeding.
Correct answer: A
Rationale: Letting an infant cry for prolonged periods can exacerbate colic and increase the infant's distress. It is better to respond promptly to soothe the baby. Other methods like swaddling, gentle massage, and keeping the infant upright can help relieve colic symptoms.
4. The nurse is planning an educational session with a group of school-age children. Which primary task from Erikson’s theory of psychosocial development should be addressed?
- A. Establishing trust in others
- B. Developing a sense of autonomy
- C. Developing a sense of industry
- D. Establishing a sense of identity
Correct answer: C
Rationale: In Erikson’s theory of psychosocial development, school-age children typically focus on developing a sense of industry. This stage, occurring during middle childhood, involves the desire to feel competent and productive in their skills and abilities. Choices A, B, and D are incorrect because establishing trust in others (A) is related to the first stage of Erikson's theory (trust vs. mistrust) which occurs in infancy, developing a sense of autonomy (B) is linked to the second stage (autonomy vs. shame and doubt) which occurs in early childhood, and establishing a sense of identity (D) is associated with the fifth stage (identity vs. role confusion) which occurs in adolescence.
5. While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?
- A. The 6-month-old in deep sleep
- B. The 2-year-old who is cooperative when the nurse takes vital signs
- C. The 4-year-old who is actively watching cartoons
- D. The 14-month-old who is screaming and thrashing his arms and legs
Correct answer: D
Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.
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