ATI Quiz 5 Practice Questions with Rationales

ATI Quiz 5 Practice Questions with Rationales 1. A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further intervention? a. Positive Babinski reflex R The Babinski reflex disappears after 1 year of age. Therefore, a 9-month-old infant with a positive Babinski reflex is a finding that does not require further intervention. b. Positive Moro reflex R The Moro reflex disappears approximately at 3-4 months of age. Therefore, a 9- month-old infant with a positive Moro reflex is a finding that requires further intervention c. Negative Doll’s eye reflex R A negative Doll’s eye reflex is a normal finding. Therefore, a 9-month-old infant with a negative Doll’s eye reflex is a finding that does not require further intervention. d. Negative Crawl reflex R A negative Crawl reflex disappears after 6 months of age. Therefore, a 9-month-old infant with a negative Crawl reflex is a finding that does not require further intervention. 2. A nurse working in a pediatric clinic is collecting data on a preschool-age child who has a rash on his arm. The mother reports that the child was recently exposed to impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection? a. Scaling patches that are clear in the center. R This finding is associated with tinia corporis (ringworm), not impetigo. b. Honey-colored crusts caused by dried exudate. R This finding is associated with impetigo contagiosa. Honey-colored crusts develop when vesicles rupture and the exudate dries. c. Firm papules with a roughened, finely papillomatous texture. R This finding is associated with verruca (warts), not impetigo. d. Lines of small blisters surrounding one large blister. R This finding is associated with poison ivy, not impetigo. 3. A nurse is collecting data from an 11-month-old infant. Which of the following clinical manifestations is suggestive of a central nervous system infection? a. Oliguria R Oliguria is a clinical manifestation of shock or kidney disease. However, it is not a clinical manifestation of a central nervous system infection. b. Bulging fontanel R A central nervous system infection causes increased intracranial pressure. Therefore, bulging fontanels are a clinical manifestation of a central nervous system infection. c. Negative Brudzinski sign R A positive Brudzinski sign is a clinical manifestation of a central nervous system infection. d. Jaundice R Jaundice is a clinical manifestation of liver disease. However, not a clinical manifestation of a central nervous system infection. 4. A nurse is reinforcing teaching to an adolescent client regarding administration of Gardasil vaccine. For which of the following sexually transmitted infections does the vaccine provide immunity? a. Human papillomavirus (HPV) R Gardasil is the only HPV vaccine that helps provide immunity against 4 types of HPV. These include type 6, 11, 16, and 18. The immunization schedule for Gardasil is 3 injections over a 6 month period. Clients should receive this vaccine between the ages of 9 and 26. b. Herpes simplex virus (HSV-2) R Gardasil does not provide immunity against HSV-2. c. Chlamydia trachomatis R Gardasil does not provide immunity against chlamydia trachomatis. d. Gonorrhea R Gardasil does not provide immunity against gonorrhea. 5. A nurse is caring for a 4-year-old child who had hydrocephalus as an infant and is admitted with a malfunctioning ventriculoperitoneal shunt. Following new shunt placement, the nurse conducts a postoperative check. Which of the following findings requires immediate action by the nurse? a. Sleepy and very difficult to arouse R The child may be sleepy following surgery but should be easily aroused. Lethargy could indicate a decreased level of consciousness or increasing intracranial pressure and should be reported immediately. b. Lying flat on the unaffected side R The child should be positioned on the unaffected side to avoid pressure on the shunt valve. Lying flat is often prescribed after initial shunt placement, not necessarily after elective replacement. If the child has signs of increasing intracranial pressure, the provider might prescribe upright positioning. c. BP 100/60, apical pulse rate of 90 R These vital signs are within the expected range for a 4-year-old child. d. Urine output 50 mL in 2 hr R A urine output of 50 mL in 2 hr indicates adequate renal function for a 4-year-old child. 6. A nurse is caring for a toddler scheduled to have a lumbar puncture (LP) to rule out meningitis. The nurse who is planning to assist with the procedure should a. have another nurse to help hold the toddler. R One nurse should be able to assist with the procedure. b. sit the toddler on the side of bed. R This is not an appropriate position for a toddler who is being prepared for a lumbar puncture. c. place the toddler in a side-lying, knee-chest position. R A lumbar puncture (LP) is a procedure in which a small amount of the fluid that surrounds the brain and spinal cord called the cerebrospinal fluid, or CSF, is removed and examined. The client is positioned on the side in a fetal position (knees curled to abdomen and chin tucked to chest). d. use a mummy restraint. R Mummy restraints may be used when performing a procedure such as suturing a facial laceration, but it would place the child in an inappropriate position when performing an lumbar puncture. 7. A nurse is caring for a child who just underwent insertion of a ventriculoperitoneal shunt. Which of the following positions would be appropriate for the client? a. On the operative side R On the operative side is not an appropriate position for this client. b. A 45-degree head elevation R A 45-degree elevation of the head of bed is not the appropriate position for this client. c. Prone R Lying on the stomach is not the appropriate position for this client. d. Dorsal recumbent R Lying flat on the back is the appropriate position for this client. This position keeps the head level with the body, which reduces the risk of cerebrospinal fluid flowing too rapidly, leading to rapid decompression, which can result in tearing of the cerebral arteries. 8. A nurse is caring for a child who is having a seizure. Which of the following is an appropriate action by the nurse? (Select all that apply.) a. Check the client’s airway for patency. R Assess the client’s airway patency is correct. This is an appropriate action by the nurse. b. Place a tongue depressor in the client’s mouth. R Place a tongue depressor in the client’s mouth is incorrect. Placing something in the client’s mouth can cause injury, and is not an appropriate action by the nurse. c. Place the bed in a low position. R Place the bed in a low position is correct. This is an appropriate action by the nurse. d. Place the client in prone position. R Place the client in prone position is incorrect. The client should be positioned side- lying to prevent aspiration of secretions or vomit. e. Restrain the client. R Restrain the client is incorrect. Restraining the client can cause injury, and is not an appropriate action by the nurse. 9. A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? a. Administer antibiotics when available. R The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness. b. Reduce environmental stimuli. R Reducing environmental stimuli is an appropriate action by the nurse; however, this is not the priority. c. Document intake and output. R Documenting intake and output is an appropriate action by the nurse; however, this is not the priority. d. Maintain seizure precautions. R Maintaining seizure precautions is an appropriate action by the nurse; however, this is not the priority. 10. A nurse is instructing a mother on how to care for a child who has impetigo contagiosa. Which of the following should the nurse plan to include in her education of the mother? a. Isolate this child from others in his family. R The mother should know isolation precautions are not needed; however, limiting contact with others when the wound is weeping will prevent spread of the infection. b. Wash toys with soap and very hot water. R The mother should know to wash the toys with soap and hot water to disinfect and prevent the spread of the infection. c. Vaccinated the other family member for disease. R The mother should know there is no vaccination for the infection d. Implement no special precautions. R The mother should know to implement universal precautions to prevent the spread of the infection.