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

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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. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?

Correct answer: A

Rationale: The best response by the nurse is A, as the anterior fontanel typically closes between 12-18 months of age, allowing for brain growth during infancy. Choice B is incorrect because it does not provide a specific timeframe for the closure of the fontanel. Choice C is incorrect as it suggests a later closure timeframe than usual. Choice D is incorrect as it states that the soft spots should have closed already, which is inaccurate for a 6-month-old infant.

3. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning?

Correct answer: A

Rationale: Clinical reasoning is purposeful and goal-directed, involving the use of critical thinking and decision-making skills to provide effective patient care.

4. A child diagnosed with a soft tissue tumor is being treated with chemotherapy. Prior to administering the chemotherapy, which laboratory test should the nurse monitor to determine if the child has any capability of fighting infections?

Correct answer: D

Rationale: The Absolute Neutrophil Count (ANC) is crucial for determining the child's ability to fight infections. Neutrophils play a key role in combating bacterial infections. Monitoring the ANC is essential before administering chemotherapy, as a low ANC indicates an increased risk of infection. Hemoglobin, red blood cell count, and platelets are important for assessing oxygen-carrying capacity, anemia, and clotting function, respectively, but they do not directly reflect the child's capability to fight infections.

5. The nurse is caring for an adolescent who has just started dialysis. The child always seems angry, hostile, or depressed. The nurse should recognize that this is most likely related to what underlying cause?

Correct answer: D

Rationale: Adolescents may feel anger and depression due to the loss of independence and control over their lives, which is imposed by the need for regular dialysis treatments. This reaction is common as they struggle with the restrictions placed on their social and personal lives.

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