ATI RN
Nursing Care of Children ATI
1. Which characteristic best describes the fine motor skills of an infant at age 5 months?
- A. Neat pincer grasp
- B. Strong grasp reflex
- C. Builds a tower of two cubes
- D. Able to grasp object voluntarily
Correct answer: D
Rationale: By 5 months, infants develop the ability to grasp objects voluntarily, showing improved motor control. The neat pincer grasp and building towers are skills that develop later.
2. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?
- A. Refer him for immediate medical evaluation
- B. Administer analgesics and recommend scrotal support.
- C. Apply an ice bag and observe for increasing pain.
- D. Reassure the adolescent that occasional pain is common with the changes of puberty.
Correct answer: A
Rationale: Sudden and severe scrotal pain in an adolescent male is a medical emergency and may indicate testicular torsion, which requires immediate evaluation and intervention to prevent testicular loss.
3. The nurse is aware that skin turgor best estimates what?
- A. Perfusion
- B. Adequate hydration
- C. Amount of body fat
- D. Amount of anemia
Correct answer: B
Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.
4. What is the most frequent cause of hypovolemic shock in children?
- A. Sepsis
- B. Blood loss
- C. Anaphylaxis
- D. Heart failure
Correct answer: B
Rationale: Hypovolemic shock in children is most frequently caused by blood loss, which can result from trauma, surgery, or gastrointestinal bleeding. Sepsis and anaphylaxis can lead to different types of shock (septic and anaphylactic), and heart failure is related to cardiogenic shock.
5. According to Piaget, a 6-month-old infant should be in which developmental stage?
- A. Use of reflexes
- B. Primary circular reactions
- C. Secondary circular reactions
- D. Coordination of secondary schemata
Correct answer: C
Rationale: By 6 months, infants are usually in the stage of secondary circular reactions, where they start to intentionally repeat actions that bring pleasure or interesting results.
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