ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
- A. All below
- B. Oliguria
- C. Confusion
- D. Pale extremities
Correct answer: A
Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.
2. The nurse is caring for a child who had a tonsillectomy. Which clinical manifestation should the nurse observe the child for in the postoperative period?
- A. Arrhythmias
- B. Increased swallowing
- C. Increased blood sugar
- D. Increased urinary output
Correct answer: B
Rationale: Correct Answer: B. Increased swallowing can indicate bleeding at the surgical site, which is a potential complication after tonsillectomy. Choice A, Arrhythmias, are not typically associated with tonsillectomy. Choice C, Increased blood sugar, is not a common clinical manifestation after a tonsillectomy. Choice D, Increased urinary output, is not a typical clinical manifestation to observe for in the postoperative period after a tonsillectomy.
3. Evidence-based practice (EBP), a decision-making model, is best described as which?
- A. Using information in textbooks to guide care
- B. Combining knowledge with clinical experience and intuition
- C. Using a professional code of ethics as a means for decision-making
- D. Gathering all evidence that applies to the child’s health and family situation
Correct answer: D
Rationale: Evidence-based practice involves gathering and integrating all relevant evidence to guide clinical decision-making, ensuring that care is based on the best available research.
4. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?
- A. Request a detailed listing of symptoms.
- B. Ask the adolescent, "Why did you come here today?"
- C. Interview the parent away from the adolescent to determine the chief complaint
- D. Use what the adolescent says to determine, in correct medical terminology, what the problem is
Correct answer: B
Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.
5. What problem is most often associated with myelomeningocele?
- A. Biliary atresia
- B. Hydrocephalus
- C. Craniostenosis
- D. Tracheoesophageal fistula
Correct answer: B
Rationale: Hydrocephalus is the most commonly associated problem with myelomeningocele, present in 80% to 90% of affected children. Biliary atresia and tracheoesophageal fistula are not typically associated with myelomeningocele. Craniostenosis refers to the premature closing of cranial sutures and is not a common issue seen with myelomeningocele.
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