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. What should the nurse include in the discharge instructions for the parents of an infant diagnosed with acute otitis media?
- A. Keep the baby in an elevated position during sleep
- B. Administer an antibiotic
- C. Place the baby to sleep with a bottle
- D. Administer acetaminophen (Tylenol) to relieve discomfort
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.
3. What is characteristic of a neonate’s vision?
- A. Pupils react to light
- B. Tear glands function
- C. Blink reflex is absent
- D. Ciliary muscles are mature
Correct answer: A
Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.
4. A foster parent is talking to the nurse about the health care needs for the child who has been placed in the parent's care. Which statement best describes the health care needs of foster children?
- A. Foster children always come from abusive households and are emotionally fragile.
- B. Foster children tend to have a higher than normal incidence of acute and chronic health problems.
- C. Foster children are usually born prematurely and require technologically advanced health care.
- D. Foster children will not stay in the home for an extended period, so health care needs are not as important as emotional fulfillment.
Correct answer: B
Rationale: Foster children often have higher rates of acute and chronic health problems due to a variety of factors, including previous neglect, trauma, and inconsistent healthcare access.
5. Which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days?
- A. Increased blood pressure
- B. A sunken fontanel
- C. Decreased pulse rate
- D. Low urine specific gravity
Correct answer: B
Rationale: A sunken fontanel is a classic sign of dehydration in infants, indicating a fluid volume deficit. In dehydration, the fontanel sinks due to decreased fluid volume in the body. Increased blood pressure (Choice A) is not typically associated with dehydration in infants. Decreased pulse rate (Choice C) is not a common finding in fluid volume deficit, as the body tries to increase the heart rate to compensate for decreased volume. Low urine specific gravity (Choice D) may be seen in dehydration, but it is not as specific or as easily observable as a sunken fontanel.
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