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 nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed?

Correct answer: C

Rationale: The statement about making sure others realize the child is part of the family may indicate a focus on external validation rather than on the child’s needs and identity, suggesting a need for further teaching.

3. A major reason for the development of respiratory distress syndrome in the preterm infant is:

Correct answer: B

Rationale: The correct answer is B: Lack of surfactant. Respiratory distress syndrome (RDS) in preterm infants is primarily due to a lack of surfactant, which is crucial for keeping the lungs inflated. Without adequate surfactant, the alveoli collapse, leading to breathing difficulties. Choice A, Excessive surfactant, is incorrect as RDS is caused by an insufficient amount of surfactant. Choice C, Immature immune system, and Choice D, Lack of body fat, are not directly related to the development of respiratory distress syndrome in preterm infants.

4. Children may believe that they are responsible for their parents' divorce and interpret the separation as punishment. At which age is this most likely to occur?

Correct answer: C

Rationale: At around 8 years old, children may feel they are responsible for their parents' divorce and view it as a punishment, which can impact their emotional well-being.

5. Which one of the following strategies might be recommended for an infant with failure to thrive (FTT) to increase caloric intake?

Correct answer: B

Rationale: Being persistent through 10 to 15 minutes of food refusal is recommended to help increase caloric intake in infants with FTT. Establishing a routine and using developmental stimulation can also be helpful, but the priority is ensuring adequate caloric intake.

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