ATI RN
ATI Nursing Care of Children 2019 B
1. Which of the following is a characteristic finding in Kawasaki disease?
- A. Strawberry tongue
- B. Polyarthritis
- C. Hematuria
- D. Rashes
Correct answer: A
Rationale: A 'strawberry tongue' is a characteristic finding in Kawasaki disease. The presence of a 'strawberry tongue' is a classic sign of Kawasaki disease, along with other features such as conjunctivitis and rash. Choice B, polyarthritis, is not typically seen in Kawasaki disease. Choice C, hematuria, is not a common finding in Kawasaki disease but may be seen in other conditions. Choice D, rashes, are present in Kawasaki disease but are not as specific or characteristic as the 'strawberry tongue'. Therefore, the correct answer is A.
2. What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid using alkaline-based soap.
- B. Bathe the infant with sterile water.
- C. Cleanse skin with a gentle alkaline-based soap and water.
- D. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
Correct answer: B
Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.
3. Which explains the importance of detecting strabismus in young children?
- A. Color vision deficit may result.
- B. Amblyopia, a type of blindness, may result.
- C. Epicanthal folds may develop in the affected eye
- D. Corneal light reflexes may fall symmetrically within each pupil
Correct answer: B
Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.
4. The LPN is caring for a 1-month-old patient post-surgery. Which pain scale is expected to be used to evaluate post-op pain?
- A. Oucher
- B. Wong-Baker FACES
- C. FLACC
- D. 0-10 pain scale
Correct answer: C
Rationale: The FLACC (Face, Legs, Activity, Cry, Consolability) scale is commonly used to assess pain in infants and young children who are unable to verbally communicate their pain. This scale is particularly useful in assessing post-operative pain in infants as it evaluates different behaviors and physiological responses to pain. The Oucher scale is more commonly used with children who are older and can provide self-report of pain intensity. Wong-Baker FACES scale is primarily used with children who are older and can indicate their pain level by pointing to facial expressions. The 0-10 pain scale is typically used with older children and adults who can rate their pain on a numerical scale.
5. A 3-year-old child, previously potty-trained, becomes a bed-wetter again during a hospital stay. Which explanation should the nurse provide to the parents?
- A. “Your child is no longer potty-trained and will need to be retrained when she goes home.”
- B. “The child may have developed a bladder infection in the hospital. I will notify the doctor.”
- C. “Preschool children may regress in their behaviors when they are ill in the hospital but should return to normal when they go back home.”
- D. “Don’t worry about it, she is fine.”
Correct answer: C
Rationale: During a hospital stay, preschool children may exhibit regression in behaviors such as bed-wetting due to stress. It is important for parents to understand that this behavior is a common response to the hospital environment and should resolve once the child is back home. Therefore, the correct explanation for the nurse to provide to the parents is choice C. Choice A is incorrect because it inaccurately states that the child is no longer potty-trained. Choice B is incorrect as it assumes a medical issue without evidence. Choice D is incorrect as it dismisses the parents' concerns without addressing the underlying cause of the behavior.
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