the nurse is taking a health history of an adolescent which best describes how the chief complaint should be determined

ATI RN

ATI Nursing Care of Children

1. 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.

2. What is characteristic of a neonate’s vision?

A. Pupils react to light
B. Tear glands function
C. Blink reflex is absent
D. Ciliary muscles are mature

Correct answer: A

Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.

3. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?

A. Explain that it will not be painful.
B. Suggest to him that he not worry about losing just a little bit of blood.
C. Discuss with him how his body is always in the process of making blood.
D. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.

Correct answer: C

Rationale: Discussing how the body continuously makes blood helps the child understand that losing a small amount is normal and not harmful. This educational approach also helps reduce anxiety by giving the child a sense of control over the situation.

4. What findings on physical assessment of a neonate would indicate the need for further evaluation?

A. Nystagmus
B. Epstein pearls
C. Low-set ears
D. Positive Babinski reflex

Correct answer: C

Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.

5. What name is given to inflammation of the bladder?

A. Cystitis
B. Urethritis
C. Urosepsis
D. Bacteriuria

Correct answer: A

Rationale: Cystitis is the medical term for inflammation of the bladder. Urethritis refers to inflammation of the urethra, urosepsis to a systemic infection stemming from the urinary tract, and bacteriuria to the presence of bacteria in the urine.