what physiologic states produces the clinical manifestations of nervous system stimulation and excitement such as overexcitability nervousness and tet
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

Correct answer: D

Rationale: Both metabolic and respiratory alkalosis can cause overexcitability and nervous system stimulation due to a decrease in ionized calcium levels, which can cause symptoms such as tetany and paresthesias. Acidosis typically has the opposite effect, leading to depression of the nervous system.

2. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

3. The nurse is admitting a child with severe isotonic dehydration. Which intravenous fluid should the nurse anticipate the doctor to order initially to replace fluids?

Correct answer: A

Rationale: In the case of severe isotonic dehydration, the initial fluid of choice is 0.9% normal saline. This solution is preferred because it helps to restore both fluids and electrolytes effectively. Options B, C, and D are not suitable for the initial management of severe isotonic dehydration. D5 0.2% (1/4) normal saline (Choice B) is a hypotonic solution and might worsen the imbalance. D5W (Choice C) is a hypotonic solution that does not contain electrolytes essential for rehydration. Albumin (Choice D) is a colloid solution used for specific indications like hypoproteinemia or hypoalbuminemia, not for initial rehydration in severe dehydration.

4. Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?

Correct answer: D

Rationale: Hypernatremia often presents with dry, sticky mucous membranes due to dehydration. Hyperreflexia and abdominal cramps may also occur, but dry mucous membranes are more consistently observed in cases of sodium excess.

5. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?

Correct answer: B

Rationale: At 2 months, infants typically react to loud noises with the Moro reflex, a startle response that is normal at this stage of development.

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