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. The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER) before discharge. What instructions should the nurse include?

Correct answer: D

Rationale: Cimetidine is an H2 blocker that reduces stomach acid, helping manage GER. Holding the infant in the prone position is not recommended due to the risk of SIDS. Breastfeeding should not be discontinued unless advised by a physician. Elevating the head to 90 degrees is excessive.

3. A 4-month-old infant is discharged home after surgery for the repair of a cleft lip. What should instructions to the parents include?

Correct answer: C

Rationale: Pain management is essential postoperatively to reduce crying, which could place strain on the surgical site. Feeding and holding the infant are allowed, but care should be taken to avoid placing pressure on the suture line.

4. What is the most consistent and commonly used indicator of pain in infants?

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

5. Children may believe that they are responsible for their parents' divorce and interpret the separation as punishment. At which age is this most likely to occur?

Correct answer: C

Rationale: At around 8 years old, children may feel they are responsible for their parents' divorce and view it as a punishment, which can impact their emotional well-being.

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