the nurse is preparing a presentation on compensated decompensated and irreversible shock in children what clinical manifestations related to decompen
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Nursing Elites

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.)

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. During the nurse’s initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. What action should the nurse take?

Correct answer: B

Rationale: Pain management should be based on the child’s report of pain, regardless of their activity level. Administering the prescribed analgesic is the appropriate action. Reassessing the child in 15 minutes without providing immediate pain relief may not be in the child's best interest. Doing nothing since the child appears to be resting may lead to inadequate pain management. Asking the child’s parents if they think the child is hurting does not replace the need for direct assessment and intervention by the nurse.

3. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?

Correct answer: D

Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.

4. When assessing a family, the nurse determines that the parents exert little or no control over their children. This style of parenting is called which?

Correct answer: A

Rationale: Permissive parenting is characterized by parents exerting little or no control over their children, leading to a lack of boundaries and structure.

5. The nurse is reviewing the importance of role learning for children. The nurse understands that children's roles are primarily shaped by which members?

Correct answer: B

Rationale: Parents play the primary role in shaping their children's roles and behaviors, especially in early childhood, through modeling, guidance, and expectations.

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