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ATI Nursing Care of Children 2019 B
1. What is the most appropriate intervention for a child with suspected acute appendicitis?
- A. Administer antibiotics
- B. Apply heat to the abdomen
- C. Encourage oral fluids
- D. Prepare for surgery
Correct answer: D
Rationale: The correct answer is D: Prepare for surgery. Acute appendicitis is a surgical emergency that requires prompt removal of the appendix to prevent complications like rupture and peritonitis. Administering antibiotics (choice A) may be part of the treatment plan but should not delay surgical intervention. Applying heat to the abdomen (choice B) is not recommended as it can worsen the inflammation of the appendix. Encouraging oral fluids (choice C) is generally beneficial, but the priority in acute appendicitis is surgical intervention.
2. Which reflex is expected to disappear by 4 months of age?
- A. Rooting reflex
- B. Moro reflex
- C. Babinski reflex
- D. Palmar grasp
Correct answer: B
Rationale: The Moro reflex, also known as the startle reflex, typically disappears by 4 months as the infant's nervous system matures. This reflex is important for assessing the development of the nervous system in newborns. The Rooting reflex (Choice A) is related to turning the head in response to cheek stimulation; the Babinski reflex (Choice C) involves the fanning of toes in response to foot stimulation; and the Palmar grasp (Choice D) is the curling of the fingers around an object placed in the infant's hand. These reflexes have different timelines for disappearance and are not typically expected to be gone by 4 months of age.
3. When a pre-school child says the sun shines to keep her warm, this is an example of:
- A. Animism
- B. Artificialism
- C. Egocentrism
- D. Centering
Correct answer: B
Rationale: The correct answer is B: Artificialism. Artificialism is the belief that natural phenomena are created by human beings for human purposes. In this scenario, the child attributes human-like intentions to the sun, assuming it shines specifically to keep her warm. Choice A, Animism, is the belief that natural objects and phenomena are alive and have feelings. Choice C, Egocentrism, refers to a child's difficulty in seeing things from another person's perspective. Choice D, Centering, involves focusing on only one aspect of a situation while ignoring other relevant aspects.
4. What urine test result is considered abnormal?
- A. pH 4.0
- B. WBC 1 or 2 cells/ml
- C. Protein level absent
- D. Specific gravity 1.020
Correct answer: A
Rationale: A urine pH of 4.0 is abnormally low, indicating possible acidosis or other metabolic conditions. WBC count of 1-2 cells/ml, absence of protein, and a specific gravity of 1.020 are within normal limits.
5. The nurse is teaching the mother of a 9-month-old infant about administering liquid iron preparation. Which information should be included in the teaching?
- A. Adequate dosage will turn the stools a tarry, black color.
- B. Give Vitamin D to enhance absorption.
- C. Allow the liquid iron to mix with saliva before swallowing.
- D. Give the liquid iron with meals.
Correct answer: A
Rationale: The correct answer is A. Iron supplements can cause stools to turn black, which is a normal and harmless side effect. Iron is best absorbed on an empty stomach, although it can be given with food if gastrointestinal upset occurs. Vitamin C, not D, enhances iron absorption. Choice B is incorrect because Vitamin C enhances iron absorption, not Vitamin D. Choice C is incorrect as there is no need to mix liquid iron with saliva before swallowing. Choice D is incorrect because iron is best absorbed on an empty stomach.
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