ATI RN
Nursing Care of Children ATI
1. What is characteristic of a neonate’s vision?
- A. Pupils react to light
- B. Tear glands function
- C. Blink reflex is absent
- D. Ciliary muscles are mature
Correct answer: A
Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.
2. The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment?
- A. A white reflex
- B. Blue-tinged sclerae
- C. A red reflex
- D. Yellow-tinged sclerae
Correct answer: A
Rationale: The correct answer is A: A white reflex. The 'white reflex' or leukocoria is a common sign of retinoblastoma. It occurs when the light reflects off the tumor in the eye, giving the pupil a white appearance instead of the normal red reflex. Blue-tinged sclerae (choice B) and yellow-tinged sclerae (choice D) are not typical manifestations of retinoblastoma. A red reflex (choice C) is the normal reflection seen in the eye when light is shone on it and is not associated with retinoblastoma.
3. With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?
- A. 10th percentile
- B. 75th percentile
- C. 85th percentile
- D. 95th percentile
Correct answer: C
Rationale: A BMI-for-age at the 85th percentile indicates a child is at risk for being overweight, according to the National Center for Health Statistics criteria.
4. The LPN is caring for a 1-month-old patient post-surgery. Which pain scale is expected to be used to evaluate post-op pain?
- A. Oucher
- B. Wong-Baker FACES
- C. FLACC
- D. 0-10 pain scale
Correct answer: C
Rationale: The FLACC (Face, Legs, Activity, Cry, Consolability) scale is commonly used to assess pain in infants and young children who are unable to verbally communicate their pain. This scale is particularly useful in assessing post-operative pain in infants as it evaluates different behaviors and physiological responses to pain. The Oucher scale is more commonly used with children who are older and can provide self-report of pain intensity. Wong-Baker FACES scale is primarily used with children who are older and can indicate their pain level by pointing to facial expressions. The 0-10 pain scale is typically used with older children and adults who can rate their pain on a numerical scale.
5. The nurse is planning an educational session with a group of school-age children. Which primary task from Erikson’s theory of psychosocial development should be addressed?
- A. Establishing trust in others
- B. Developing a sense of autonomy
- C. Developing a sense of industry
- D. Establishing a sense of identity
Correct answer: C
Rationale: In Erikson’s theory of psychosocial development, school-age children typically focus on developing a sense of industry. This stage, occurring during middle childhood, involves the desire to feel competent and productive in their skills and abilities. Choices A, B, and D are incorrect because establishing trust in others (A) is related to the first stage of Erikson's theory (trust vs. mistrust) which occurs in infancy, developing a sense of autonomy (B) is linked to the second stage (autonomy vs. shame and doubt) which occurs in early childhood, and establishing a sense of identity (D) is associated with the fifth stage (identity vs. role confusion) which occurs in adolescence.
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