ATI RN
RN Nursing Care of Children 2019 With NGN
1. What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?
- A. Place an ice pack on the scrotal area.
- B. Place the child in an upright sitting position.
- C. Elevate the scrotum with a rolled washcloth.
- D. Place a warm moist pack to the scrotal area.
Correct answer: C
Rationale: Elevating the scrotum with a rolled washcloth helps reduce edema by promoting fluid drainage. Ice packs are not recommended due to the risk of frostbite, and warm moist packs are not typically used for this purpose. An upright position does not specifically address the edema.
2. The nurse is aware that which age group is at risk for childhood injury because of the cognitive characteristic of magical and egocentric thinking?
- A. Preschool
- B. Young school age
- C. Middle school age
- D. Adolescent
Correct answer: A
Rationale: Preschool children are at higher risk for injury due to magical and egocentric thinking, which can lead to misjudgments about their abilities and dangers.
3. An eleven-year-old boy is admitted with a history of type 1 diabetes. What information about school age should the nurse use to formulate the teaching plan for daily injections?
- A. The parents do not need to learn the procedure.
- B. The child is old enough to give most of his injections.
- C. Self-injections will be possible when he is closer to adolescence.
- D. The child can learn about self-injections when he is able to reach all injection sites.
Correct answer: B
Rationale: By the age of eleven, many children are capable of administering their own insulin injections with supervision, fostering independence and better management of their diabetes. This age is appropriate for the child to take on more responsibility for their care. While parental involvement is still crucial for supervision and guidance, the child can start to learn and perform the injections themselves. Choice A is incorrect because parental involvement is important for safety and proper technique. Choice C is incorrect as waiting until closer to adolescence may delay the child's ability to manage their diabetes effectively. Choice D is incorrect as reaching injection sites is not the sole criteria; proper technique and supervision are essential.
4. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?
- A. Retake the temperature in 15 minutes after giving the Tylenol.
- B. Place a warm blanket on the child so chilling does not occur.
- C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
- D. Use cold compresses instead of Tylenol to control the fever.
Correct answer: C
Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.
5. During which phase of the nursing process does the nurse use essential information about the child’s physical, social, and emotional health to decide which interventions to use?
- A. Implementation
- B. Planning
- C. Diagnosis
- D. Assessment
Correct answer: B
Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse utilizes essential information gathered during the assessment about the child’s physical, social, and emotional health to determine the most appropriate interventions to address the identified needs. This phase focuses on developing a comprehensive care plan tailored to the individual child. A) Implementation is incorrect because this phase involves carrying out the interventions outlined in the care plan. C) Diagnosis is incorrect as it refers to identifying health issues based on the assessment data. D) Assessment is incorrect as it involves collecting and analyzing data about the child's health status, rather than deciding on interventions.
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