ATI RN
Nursing Care of Children Final ATI
1. Which responsibilities are included in the pediatric nurse's promotion of the health and well-being of children? (Select all that apply.)
- A. Promoting disease prevention
- B. Providing financial assistance
- C. Providing support and counseling
- D. A, C
Correct answer: D
Rationale: Pediatric nurses promote health through disease prevention, support, counseling, therapeutic relationships, and participating in ethical decision-making.
2. Which action should the nurse implement when taking an axillary temperature?
- A. Take the temperature through one layer of clothing
- B. Add a degree to the result when recording
- C. Place the tip of the thermometer under the arm in the center of the axilla
- D. Hold the child's arm away from the body while taking the temperature
Correct answer: C
Rationale: The correct technique involves placing the thermometer tip in the center of the axilla to ensure an accurate reading, with the arm held close to the body.
3. Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, while the other is stacking blocks. Which type of play is this?
- A. Cooperative play
- B. Solitary play
- C. Parallel play
- D. Associative play
Correct answer: C
Rationale: The correct answer is C, parallel play. Parallel play is observed when children play alongside each other but do not directly interact. In this scenario, each child is engaged in their own activity without engaging or influencing each other's play, which characterizes parallel play. Cooperative play (choice A) involves children playing together towards a common goal, which is not evident in the given situation. Solitary play (choice B) is when a child plays alone, unrelated to the presence of others. Associative play (choice D) involves more interaction and sharing of toys between children, which is not happening in the described play scenario.
4. Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?
- A. High serum pH
- B. Normal serum pH
- C. Metabolic alkalosis
- D. Metabolic acidosis
Correct answer: D
Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.
5. The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?
- A. One portion of the intestines invaginates or telescopes into another
- B. Hypertrophy of the circular pylorus muscle
- C. Relaxed cardiac sphincter
- D. Absent ganglion cells in the colon
Correct answer: B
Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.
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