ATI RN
RN Nursing Care of Children 2019 With NGN
1. 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.
2. When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?
- A. Petechiae, fever, fatigue
- B. Headache, papilledema, irritability
- C. Muscle wasting, weight loss, fatigue
- D. Decreased intracranial pressure, psychosis, confusion
Correct answer: A
Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.
3. The school nurse understands that children are impacted by divorce. Which has the most impact on the positive outcome of a divorce?
- A. Age of the child
- B. Gender of the child
- C. Family characteristics
- D. Ongoing family conflict
Correct answer: D
Rationale: The level of ongoing family conflict is the most significant factor influencing the positive or negative outcomes for children during and after a divorce
4. The nurse has completed an education program on normal communication abilities in the preschool-age child. Which statement by a participant indicates a need for further education?
- A. When my child counts numbers, it is only to 10 and we are slowly working on counting higher.
- B. I am glad to know that my 4-year-old child asking so many questions is normal.
- C. Stating his name and address is too hard for my 5-year-old child; it will be another year before he can do that.
- D. My child is finally talking in a way that most of my friends can understand her speech.
Correct answer: C
Rationale: The correct answer is C. By age 5, children should be able to state their name and address. If a child cannot do this, it may indicate a developmental delay that requires further assessment. Choices A, B, and D do not indicate a need for further education as they reflect typical developmental milestones for preschool-age children, such as gradually improving counting skills, asking many questions, and improving speech clarity over time.
5. The nurse is caring for a child with the following order: Methylprednisolone (Solu-Medrol) 20 mg IV, every 6 hours. The nurse has Methylprednisolone 100 mg in 2 mL available. How many mL should the nurse administer with each dose?
- A. 0.4 mL
- B. 0.2 mL
- C. 0.5 mL
- D. 0.6 mL
Correct answer: A
Rationale: The correct dosage to administer 20 mg is 0.4 mL, calculated by dividing the dose (20 mg) by the concentration (100 mg in 2 mL). This calculation ensures the accurate administration of the prescribed medication. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided concentration of the medication.
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