which actions by the nurse demonstrate clinical reasoning select all that apply

ATI RN

Nursing Care of Children Final ATI

1. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

A. All below
B. Considering alternative actions
C. Using formal and informal thinking to gather data
D. Giving deliberate thought to a patient's problem

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

2. What do mortality statistics describe?

A. Disease occurring regularly within a geographic location
B. The number of individuals who have died over a specific period
C. The prevalence of specific illness in the population at a particular time
D. Disease occurring in more than the number of expected cases in a community

Correct answer: B

Rationale: Mortality statistics describe the number of individuals who have died over a specific period, providing insight into public health concerns.

3. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?

A. Request a detailed listing of symptoms.
B. Ask the adolescent, "Why did you come here today?"
C. Interview the parent away from the adolescent to determine the chief complaint
D. Use what the adolescent says to determine, in correct medical terminology, what the problem is

Correct answer: B

Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.

4. Which of the following conditions is characterized by a 'machine-like' murmur in children?

A. Patent ductus arteriosus
B. Ventricular septal defect
C. Atrial septal defect
D. Coarctation of the aorta

Correct answer: A

Rationale: The correct answer is A, Patent ductus arteriosus. This condition is characterized by a continuous 'machine-like' murmur due to abnormal blood flow between the aorta and pulmonary artery. Ventricular septal defect (choice B) is characterized by a harsh holosystolic murmur, atrial septal defect (choice C) typically presents with a fixed split S2 and a pulmonary flow murmur, and coarctation of the aorta (choice D) is associated with a systolic murmur in the back and bilateral lower extremities.

5. Which explains the importance of detecting strabismus in young children?

A. Color vision deficit may result.
B. Amblyopia, a type of blindness, may result.
C. Epicanthal folds may develop in the affected eye
D. Corneal light reflexes may fall symmetrically within each pupil

Correct answer: B

Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.