ATI RN
Nursing Care of Children ATI
1. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?
- A. The child has recently been exposed to an infectious disease
- B. The child has symptoms of a cold but no fever
- C. The child is having intermittent episodes of diarrhea
- D. The child has a disorder that causes a deficient immune system
Correct answer: D
Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.
2. Which are included in the evaluation step of the nursing process? (Select all that apply.)
- A. All below
- B. Ascertaining if the plan requires modification
- C. Determination if the outcome has been met
- D. Selecting alternative interventions if the outcome has not been met
Correct answer: A
Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.
3. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which?
- A. Abnormal and requires further investigation
- B. Abnormal unless it occurs in conjunction with knock-knee
- C. Normal if the condition is unilateral or asymmetric
- D. Normal because the lower back and leg muscles are not yet well developed
Correct answer: D
Rationale: Bowleggedness is normal in toddlers due to the development of lower back and leg muscles. It usually resolves as the child grows.
4. The nurse should assess which age group for suicide ideation since suicide in which age group is the third leading cause of death?
- A. Preschoolers
- B. Young school age
- C. Middle school age
- D. Late school age and adolescents
Correct answer: D
Rationale: Suicide is the third leading cause of death in late school-age children and adolescents, requiring careful assessment for ideation in these age groups.
5. Which of the following is a characteristic finding in Kawasaki disease?
- A. Strawberry tongue
- B. Polyarthritis
- C. Hematuria
- D. Rashes
Correct answer: A
Rationale: A 'strawberry tongue' is a characteristic finding in Kawasaki disease. The presence of a 'strawberry tongue' is a classic sign of Kawasaki disease, along with other features such as conjunctivitis and rash. Choice B, polyarthritis, is not typically seen in Kawasaki disease. Choice C, hematuria, is not a common finding in Kawasaki disease but may be seen in other conditions. Choice D, rashes, are present in Kawasaki disease but are not as specific or characteristic as the 'strawberry tongue'. Therefore, the correct answer is A.
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