the nurse is taking vital signs on a group of assigned preschool aged children which assessment finding would indicate the need for further action
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?

Correct answer: C

Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.

2. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

3. A four-year-old boy is admitted to the hospital with leg pain and fever. He is pale-looking and has bruises over various areas of his body. The physician suspects acute lymphoblastic leukemia (ALL). Which test would be used to confirm the diagnosis?

Correct answer: A

Rationale: A bone marrow aspirate is the definitive test to confirm acute lymphoblastic leukemia (ALL) in this case. It allows for the examination of leukemic cells in the bone marrow, providing a direct assessment of the disease. Red blood cell count (Choice B) is not specific for diagnosing leukemia but may show anemia commonly seen in leukemia patients. Lumbar puncture (Choice C) is used to assess central nervous system involvement, not primarily for confirming ALL. Bone scan (Choice D) is not a standard diagnostic test for ALL and is mainly used for evaluating bone metastases in other conditions.

4. The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?

Correct answer: C

Rationale: Time-outs should be in a safe, nonstimulating area, with the length typically being 1 minute per year of the child's age, not 1 hour.

5. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?

Correct answer: A

Rationale: Sudden and severe scrotal pain in an adolescent male is a medical emergency and may indicate testicular torsion, which requires immediate evaluation and intervention to prevent testicular loss.

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