ATI RN
RN Nursing Care of Children 2019 With NGN
1. 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.
2. What is an essential nursing care intervention for a neonate with a suspected tracheoesophageal fistula?
- A. Feed glucose water only.
- B. Elevate the patient's head for feedings.
- C. Raise the patient's head and give nothing by mouth.
- D. Avoid suctioning unless the infant is cyanotic.
Correct answer: C
Rationale: Raising the patient’s head and giving nothing by mouth is crucial in managing tracheoesophageal fistula. This intervention helps prevent aspiration and further complications until surgical correction can be performed. Feeding the neonate or suctioning could exacerbate the condition by risking aspiration. Elevating the head for feedings does not address the primary concern of preventing oral intake, making it less appropriate than the correct answer.
3. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?
- A. Monitor closely for signs of infection.
- B. Place the child with the operative side of the head up.
- C. Avoid pumping the shunt reservoir to maintain patency.
- D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.
Correct answer: A
Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.
4. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?
- A. Provide tactile stimulation.
- B. Administer 100% oxygen.
- C. Investigate possible causes of a false alarm.
- D. Assess infant for color and presence of respirations.
Correct answer: D
Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.
5. An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions?
- A. Justice
- B. Autonomy
- C. Beneficence
- D. Nonmaleficence
Correct answer: B
Rationale: Supporting an adolescent in making decisions about their care reflects the moral value of autonomy, emphasizing the importance of respecting the patient's right to make informed choices.
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