where is the best place to observe for the presence of petechiae in dark skinned individuals
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

Correct answer: C

Rationale: The oral mucosa and conjunctivae are the best places to observe petechiae in dark-skinned individuals because these areas have less pigmentation.

2. The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure?

Correct answer: C

Rationale: The correct answer is C because it acknowledges the child's feelings, provides clear instructions, and offers comfort and rewards to help the child cope with the procedure. Choice A is not appropriate as it may create anxiety about the injection. Choice B uses the term 'magic,' which may confuse the child and lead to fear. Choice D introduces a fantasy element that may not be beneficial in preparing the child for the injection.

3. A four-year-old boy is admitted to the hospital with leg pain and fever. He is pale-looking and has bruises over various areas of his body. The physician suspects acute lymphoblastic leukemia (ALL). Which test would be used to confirm the diagnosis?

Correct answer: A

Rationale: A bone marrow aspirate is the definitive test to confirm acute lymphoblastic leukemia (ALL) in this case. It allows for the examination of leukemic cells in the bone marrow, providing a direct assessment of the disease. Red blood cell count (Choice B) is not specific for diagnosing leukemia but may show anemia commonly seen in leukemia patients. Lumbar puncture (Choice C) is used to assess central nervous system involvement, not primarily for confirming ALL. Bone scan (Choice D) is not a standard diagnostic test for ALL and is mainly used for evaluating bone metastases in other conditions.

4. When assessing a preschooler's chest, what should the nurse expect?

Correct answer: D

Rationale: In a preschooler, chest movement should be symmetric and coordinated with breathing, indicating healthy respiratory function.

5. What should the nurse include in the discharge instructions for the parents of an infant diagnosed with acute otitis media?

Correct answer: D

Rationale: Acetaminophen (Tylenol) is recommended to help relieve the discomfort associated with acute otitis media, such as pain and fever. Elevating the baby's head during sleep can also help with drainage and relieve pressure, making choice A incorrect. Administering an antibiotic may be necessary for bacterial otitis media but is not usually the first-line treatment for acute otitis media, so choice B is incorrect. Placing the baby to sleep with a bottle can increase the risk of ear infections due to the pooling of milk around the Eustachian tube, so choice C is incorrect.

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