the nurse is caring for an adolescent hospitalized for asthma the adolescent belongs to a large family the nurse recognizes that the adolescent is lik
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. The nurse is caring for an adolescent hospitalized for asthma. The adolescent belongs to a large family. The nurse recognizes that the adolescent is likely to relate to which group?

Correct answer: A

Rationale: Adolescents typically identify and relate more closely to their peer group, especially during the teenage years when peer relationships become a central focus.

2. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Correct answer: C

Rationale: A murmur is produced by turbulent blood flow within the heart or major arteries, resulting in audible vibrations.

3. What is the most consistent and commonly used indicator of pain in infants?

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

4. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?

Correct answer: B

Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.

5. A school-age client is in the playroom when the respiratory therapist arrives to give a scheduled breathing treatment. What is the most appropriate nursing action?

Correct answer: C

Rationale: The most appropriate action is to assist the child back to their room for the treatment but reassure them that they may return when the procedure is completed. This approach ensures that the child receives the necessary treatment while also acknowledging their desire to continue playing in the playroom. Choice A is incorrect because it suggests moving the child to the room and asking the child-life specialist to bring toys, which may not be necessary. Choice B is incorrect as rescheduling the treatment may not be in the best interest of the child's health. Choice D is incorrect as the nurse should guide the child back to their room for the treatment.

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