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. Where is the best place to observe for the presence of petechiae in dark-skinned individuals?
- A. Face
- B. Buttocks
- C. Oral mucosa
- D. Palms and soles
Correct answer: C
Rationale: The oral mucosa and conjunctivae are the best places to observe petechiae in dark-skinned individuals because these areas have less pigmentation.
3. 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.
4. All of the following statements are true regarding the value of play except:
- A. Play helps preschoolers develop moral values
- B. Play helps develop muscle coordination, uses energy, and develops self-confidence
- C. Play is the work of children
- D. Play is not an effective way for the nurse to establish rapport with the child
Correct answer: D
Rationale: Play is an effective way to establish rapport with children as it helps build trust, communication, and a positive relationship. Choices A, B, and C are true statements about the value of play: A) Play helps preschoolers develop moral values by promoting social skills, cooperation, and empathy. B) Play aids in developing muscle coordination, utilizing energy, and fostering self-confidence through physical activities. C) 'Play is the work of children' emphasizes the importance of play in a child's development, learning, and creativity. Therefore, D is the correct answer as it incorrectly suggests that play is not an effective way for the nurse to establish rapport with the child.
5. 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.
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