ATI RN
RN Nursing Care of Children 2019 With NGN
1. Which clinical manifestations should the nurse anticipate when assessing a child for hypoglycemia?
- A. Lethargy
- B. Thirst
- C. Nausea and vomiting
- D. Shaky feeling and dizziness
Correct answer: D
Rationale: The correct answer is D: 'Shaky feeling and dizziness.' Hypoglycemia in children often presents with symptoms like shakiness, dizziness, sweating, hunger, and irritability. These symptoms occur because the brain and body are deprived of the glucose they need to function properly. Choices A, B, and C are incorrect because lethargy, thirst, nausea, and vomiting are not typically primary manifestations of hypoglycemia in children.
2. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?
- A. Oliguria
- B. Weight loss
- C. Irritability and seizures
- D. Muscle weakness and cardiac dysrhythmias
Correct answer: C
Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.
3. Which medication should the nurse expect to administer to a child with an acute sickle cell pain crisis?
- A. Meperidine (Demerol)
- B. Morphine
- C. Acetaminophen (Tylenol)
- D. Ibuprofen (Motrin)
Correct answer: B
Rationale: In the management of acute sickle cell pain crisis in children, morphine is the preferred medication due to its effectiveness in providing pain relief. Meperidine (Demerol) is less commonly used in this scenario because of its potential for neurotoxicity with repeated doses. Acetaminophen (Tylenol) and Ibuprofen (Motrin) are not typically sufficient for managing the severe pain associated with sickle cell crises and are not the first-line treatment options.
4. The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed?
- A. "We will try to preserve the adopted child's racial heritage."
- B. "We are glad we will be getting full medical information when we adopt our child."
- C. "We will make sure to have everyone realize this is our child and a member of the family."
- D. "We understand strangers may make thoughtless comments about our child being different from us."
Correct answer: C
Rationale: The statement about making sure others realize the child is part of the family may indicate a focus on external validation rather than on the child’s needs and identity, suggesting a need for further teaching.
5. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.)
- A. Buying clothes for the patients
- B. Showing favoritism toward a patient
- C. All
- D. Spending off-duty time with patients and families
Correct answer: C
Rationale: Overinvolvement includes personal actions like buying clothes, showing favoritism, and spending off-duty time with patients, which can blur professional boundaries.
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