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. A child is admitted with renal failure. Which of these findings should the nurse expect?

Correct answer: B

Rationale: Azotemia (elevated BUN and creatinine) and oliguria (reduced urine output) are classic signs of renal failure, indicating impaired kidney function. In renal failure, the kidneys are unable to effectively filter waste products, leading to an increase in BUN and creatinine levels in the blood. Additionally, oliguria occurs due to decreased kidney function. Increased GFR (Choice C) is not expected in renal failure as it signifies improved kidney function, which is not the case in renal failure. Polyuria and elevated creatinine clearance (Choice D) are not typical findings in renal failure. Polyuria is more commonly associated with conditions like diabetes insipidus, while elevated creatinine clearance would indicate increased kidney function, which is contrary to the impaired function seen in renal failure.

3. According to Erikson’s developmental theory, toddlers need to be encouraged to become independent to successfully complete which developmental challenge?

Correct answer: C

Rationale: The correct answer is C: Autonomy vs. shame and doubt. Erikson's developmental stage for toddlers focuses on the conflict between developing a sense of independence (autonomy) and feelings of inadequacy (shame and doubt). Encouraging toddlers to explore their environment and make choices helps them build self-confidence and independence. Choices A, B, and D are incorrect because trust vs. mistrust relates to infancy, industry vs. inferiority is associated with school-age children, and initiative vs. guilt is linked to preschoolers.

4. What is the most frequent cause of hypovolemic shock in children?

Correct answer: B

Rationale: Hypovolemic shock in children is most frequently caused by blood loss, which can result from trauma, surgery, or gastrointestinal bleeding. Sepsis and anaphylaxis can lead to different types of shock (septic and anaphylactic), and heart failure is related to cardiogenic shock.

5. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care?

Correct answer: C

Rationale: Allowing the child to make choices, such as selecting the type of juice, helps to maintain a sense of control and reduce anxiety, ensuring atraumatic care.

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