the nurse is preparing to assess a 10 month old infant he is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse is preparing to assess a 10-month-old infant. He is sitting on his father's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

Correct answer: A

Rationale: Engaging the infant in a familiar game like peek-a-boo can help reduce fear and build rapport before starting the assessment.

2. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

Correct answer: C

Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.

3. The nurse is planning an educational session with a group of school-age children. Which primary task from Erikson’s theory of psychosocial development should be addressed?

Correct answer: C

Rationale: In Erikson’s theory of psychosocial development, school-age children typically focus on developing a sense of industry. This stage, occurring during middle childhood, involves the desire to feel competent and productive in their skills and abilities. Choices A, B, and D are incorrect because establishing trust in others (A) is related to the first stage of Erikson's theory (trust vs. mistrust) which occurs in infancy, developing a sense of autonomy (B) is linked to the second stage (autonomy vs. shame and doubt) which occurs in early childhood, and establishing a sense of identity (D) is associated with the fifth stage (identity vs. role confusion) which occurs in adolescence.

4. The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal?

Correct answer: A

Rationale: Adapting ethnic practices to health needs respects the patient's cultural background while ensuring that care is effective and culturally sensitive.

5. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?

Correct answer: D

Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.

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