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

ATI RN

Nursing Care of Children Final ATI

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

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. Which of the following is a key feature of autism spectrum disorder?

Correct answer: A

Rationale: Delayed speech development is a significant feature of autism spectrum disorder. Many children with autism exhibit delays in speech and language development, which can be one of the early signs of the condition. Hyperactivity, lack of interest in toys, and aggressive behavior are not key defining features of autism spectrum disorder. While some individuals with autism may exhibit these behaviors, they are not universally characteristic of the disorder.

3. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation?

Correct answer: C

Rationale: When caring for a child with probable appendicitis, sudden relief from pain is a critical sign that could indicate perforation of the appendix. Perforation results in the release of pressure and inflammation, leading to a temporary relief of pain. Anorexia (loss of appetite) and decreased abdominal distention are symptoms commonly associated with appendicitis itself, not perforation. Bradycardia (slow heart rate) is not typically a direct manifestation of appendicitis or its complications.

4. At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infant’s crib. What is the most appropriate response for the nurse to make?

Correct answer: D

Rationale: Encouraging the baby to fall asleep in the crib while still awake can help establish healthy sleep habits and reduce night waking.

5. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

Correct answer: A

Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.

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