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ATI Nursing Care of Children 2019 B
1. What signs or symptoms are most commonly associated with the prodromal phase of acute viral hepatitis?
- A. Bruising and lethargy
- B. Anorexia and malaise
- C. Fatigability and jaundice
- D. Dark urine and pale stools
Correct answer: B
Rationale: The correct answer is B: Anorexia and malaise. The prodromal phase of acute viral hepatitis is characterized by nonspecific symptoms such as anorexia (loss of appetite) and malaise (general feeling of discomfort). These symptoms typically precede the more specific signs of jaundice, dark urine, and pale stools that manifest in the icteric phase. Choices A, C, and D are incorrect because bruising and lethargy, fatigability and jaundice, and dark urine and pale stools are typically seen in later stages of acute viral hepatitis, not in the prodromal phase.
2. What is an important intervention in providing a neutral thermal environment for an LBW infant in an incubator?
- A. Use wool blankets.
- B. Avoid using disposable diapers.
- C. Prevent heat loss.
- D. Closely monitor both incubator and rectal temperatures.
Correct answer: C
Rationale: Preventing heat loss in a low birth weight (LBW) infant is crucial in maintaining a neutral thermal environment. The use of cotton blankets is recommended over wool blankets. Avoiding disposable diapers is not directly related to maintaining a neutral thermal environment. While monitoring temperatures is important, the key intervention is preventing heat loss to ensure the infant's survival.
3. The nurse is discussing toddler development with a parent. Which intervention will foster the achievement of autonomy?
- A. Help the toddler complete tasks
- B. Encourage the toddler to do things for themselves when capable
- C. Provide opportunities for the toddler to play with other children
- D. Help the toddler learn the difference between right and wrong
Correct answer: B
Rationale: Encouraging the toddler to do things for themselves when capable is the correct intervention to foster autonomy. This approach helps the toddler develop independence, self-confidence, and a sense of achievement. Choice A is incorrect as it focuses on assisting rather than encouraging independence. Choice C is incorrect as playing with other children primarily fosters social skills, not necessarily autonomy. Choice D is incorrect as learning the difference between right and wrong is related to moral development, not autonomy.
4. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include?
- A. Dilating the stoma
- B. Assessing bowel function
- C. Limitation of physical activities
- D. Measures to prevent prolapse of the rectum
Correct answer: B
Rationale: Postoperative teaching should focus on assessing bowel function to ensure the colostomy is functioning properly. This includes monitoring stool output, color, consistency, and signs of infection or blockage. Choice A, dilating the stoma, is not recommended without healthcare provider guidance, as it can lead to complications. Choice C, limitation of physical activities, may not be as crucial immediately after colostomy creation. Choice D, measures to prevent prolapse of the rectum, is more relevant for conditions like rectal prolapse and not specifically for a colostomy.
5. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?
- A. Check the urine to see if hematuria has increased.
- B. Obtain the child's blood pressure and notify the healthcare provider.
- C. Obtain serum electrolytes and send urinalysis to the laboratory.
- D. Reassure the child and encourage bed rest until the headache improves.
Correct answer: B
Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.
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