ATI RN
RN Nursing Care of Children 2019 With NGN
1. When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?
- A. Petechiae, fever, fatigue
- B. Headache, papilledema, irritability
- C. Muscle wasting, weight loss, fatigue
- D. Decreased intracranial pressure, psychosis, confusion
Correct answer: A
Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.
2. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?
- A. Gently tap over the site.
- B. Apply a cold compress to the site.
- C. Raise the extremity above the level of the body
- D. Use a rubber band as a tourniquet for 5 minutes.
Correct answer: A
Rationale: Gently tapping over the site helps dilate the veins and increase visibility. Applying a cold compress or raising the extremity above the body level constricts the veins, making them harder to access. Prolonged tourniquet use can cause discomfort and venous congestion.
3. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?
- A. Recommend supplemental feedings of formula.
- B. Explain that this weight loss is within normal limits.
- C. Assess the child further to determine the cause of excessive weight loss.
- D. Encourage the mother to express breast milk for bottle-feeding the infant.
Correct answer: B
Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.
4. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?
- A. Avoid using any latex product.
- B. Use only non-allergenic latex products.
- C. Teach the family about long-term management of asthma.
- D. Administer medication for long-term desensitization.
Correct answer: A
Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.
5. According to Piaget, which principle supports a nine-year-old child's understanding that an arm will look the same when the IV is removed?
- A. The principle of conservation
- B. The principle of transductive reasoning
- C. The principle of identity
- D. The principle of reflex abilities
Correct answer: A
Rationale: The correct answer is A, the principle of conservation. Piaget's principle of conservation relates to a child's ability to understand that certain properties of objects remain unchanged despite modifications in their appearance. In this case, the child's understanding that an arm will look the same after the IV is removed demonstrates conservation of appearance. Choice B, transductive reasoning, involves making faulty generalizations based on specific instances and does not apply in this context. Choice C, the principle of identity, pertains to recognizing objects as the same even if they undergo transformations, which is not directly relevant to the scenario. Choice D, reflex abilities, refers to automatic responses to stimuli and is unrelated to the child's understanding of the arm's appearance post-IV removal.
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