ATI RN
RN Nursing Care of Children 2019 With NGN
1. What are signs and symptoms of a possible kidney transplant rejection in a child? (Select all that apply.)
- A. Fever
- B. Hypotension
- C. All are applicable
- D. Swelling and tenderness of graft area
Correct answer: B
Rationale: Signs of kidney transplant rejection include fever, diminished urinary output, and swelling/tenderness in the graft area. These symptoms indicate that the body may be rejecting the transplanted organ, requiring immediate medical attention.
2. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?
- A. Introduce him- or herself
- B. Make the family comfortable
- C. Give assurance of privacy
- D. Explain the purpose of the interview
Correct answer: A
Rationale: Introducing oneself is the first step in establishing a rapport and setting a professional tone for the interaction.
3. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)
- A. All below
- B. Considering alternative actions
- C. Using formal and informal thinking to gather data
- D. Giving deliberate thought to a patient's problem
Correct answer: A
Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.
4. For a child with Kawasaki disease, which symptom is most indicative of the acute phase?
- A. Strawberry tongue
- B. Joint pain
- C. Rash
- D. Peeling skin
Correct answer: A
Rationale: The correct answer is A: Strawberry tongue. In Kawasaki disease, a 'strawberry tongue' is most indicative of the acute phase. This refers to the tongue appearing red and swollen with enlarged fungiform papillae, giving it a strawberry-like appearance. Joint pain (Choice B) is more commonly associated with other conditions like rheumatoid arthritis. Rash (Choice C) and peeling skin (Choice D) are also seen in Kawasaki disease but are not as specific to the acute phase as the presence of a strawberry tongue.
5. What is a common significant side effect of opioid administration?
- A. Euphoria
- B. Diuresis
- C. Constipation
- D. Allergic reactions
Correct answer: C
Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.
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