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ATI RN Nursing Care of Children Form A

ATI RN Nursing Care of Children Form A ATI RN Nursing Care of Children Form A Scored 89% 1 Which of the following actions indicates to a nurse that the parent of a preschooler is using an age-appropriate disciplinary technique? Explains to the child why her behavior is unacceptable Places the child in time out after misbehaving Allows the child to choose the consequence for her misbehavior Assigns an extra chore for the misbehavior 2 A nurse is performing a neurological examination on a 15-month-old child. Which of the following is an expected normal finding? Negative Babinski's reflex Presence of Moro reflex Absence of corneal reflexes Positive palmar grasp 3 A home health nurse is providing teaching to the family of a child with Duchenne's muscular dystrophy. To which of the following should the home health nurse give priority? Help the family maintain the child's self-care abilities. Provide the family with a referral for a support group. Encourage the family to accept the child's limitations. Act as a liaison between the family and the school nurse. 4 A toddler is in the terminal stages of neuroblastoma. The parents are grieving and the father asks, "How can we best help our child now?" Which of the following responses by the nurse is appropriate? "Invite your child's friends to visit." "Stay close to your child." "Call your family to help you." "Talk to your child about death." 5 An infant is admitted with gastroesophageal reflux. The nurse should notify the primary care provider if which of the following occurs? Excessive crying Adventitious breath sounds Projectile vomiting Arching of the back 6 An adolescent is undergoing a lumbar puncture to confirm a diagnosis of meningitis. Following the procedure, which of the following interventions should the nurse anticipate implementing to prevent postprocedure complications? Administer an antibiotic. Give the adolescent an IV bolus of normal saline. Apply analgesic cream to the puncture site. Instruct the adolescent to lie flat for several hours. 7 A nurse is caring for a child with a tracheostomy. Which of the following techniques should the nurse use to suction the child? Insert catheter to 2 cm beyond end of tracheostomy tube. Remove catheter while applying intermittent suction. Instill saline to loosen secretions while suctioning. Continue suctioning until secretions are removed. 8 A nurse is assessing a child who has sustained a head injury. During the assessment the nurse observes clear drainage leaking from the child's nose. Which of the following nursing actions should the nurse take? Perform nasotracheal suctioning. Test the nasal secretions for glucose. Stabilize the child's spine. Lower the head of the bed. 9 A nurse is assessing an 18-month-old child. Which of the following findings should the nurse refer to the primary care provider for further evaluation? Child consistently throws items to the floor. Child scribbles on the wall with a crayon. Child crawls to navigate around the room. Child has frequent temper tantrums. 10 A nurse is planning a teaching session for parents regarding infant development. Which of the following parent activities regarding play should the nurse include in the teaching? Watch educational videos with the infant. Promote play with other infants. Engage with the infant in one-on-one play. Give the infant a large-piece puzzle. 11 A child is admitted with fever, headache, new onset of seizure activity, and nuchal rigidity. Which of the following is the first intervention the nurse should implement? Provide juice for hydration. Administer prescribed medications. Obtain current vital signs. Initiate droplet precautions. 12 A nurse is caring for a child newly diagnosed with type 1 diabetes mellitus. The nurse administers 5 units of Regular insulin according to a sliding scale before breakfast. Two hours after breakfast, the child becomes irritable, pale, diaphoretic, and shaky. Which of the following actions by the nurse is most important? Check the child's blood glucose level. Notify the primary care provider. Assess the child’s intake for breakfast. Administer 25 g of D50W. 13 A school-age child with sickle cell anemia has been admitted in vaso-occlusive crisis. Which of the following assessment findings should the nurse recognize as an emergency? Slurred speech Fever of 38.3° C (101.0° F) Hematuria Pain level of 7 on a FACES scale 14 An adolescent diagnosed with mononucleosis is brought to the primary care provider by her parent. When assessing the adolescent's current condition, which of the following should the nurse expect to find? Splenomegaly Koplik spots Maculopapular rash Paroxysmal coughing 15 A nurse is providing teaching to the family of a child with cystic fibrosis. Which of the following interventions should the nurse include in the teaching to prevent pulmonary complications? Postural drainage with percussion Humidified oxygen administration Incentive spirometry Nasal suctioning 16 A nurse is caring for a school-age child who has sustained a closed-head injury from a bicycle accident. Which of the following nursing actions is appropriate? Elevate the head of the child's bed to a 30 degree angle. Provide opioid analgesics every 3 hr. Turn the child every 4 hr. Secure the child's head with sandbags. 17 A nurse is caring for an adolescent admitted to the hospital with Epstein-Barr virus. Which of the following interventions should the nurse include in the plan of care? Collect sputum specimen. Provide disposable eating utensils. Restrict the adolescent’s visitors. Place the adolescent in a negative-pressure airflow room. 18 A mother brings her toddler to the emergency department 3 hr after she ingests an unknown quantity of acetaminophen (Tylenol). The mother asks the nurse, "What is going to happen to my child?" Which of the following responses by the nurse indicates an appropriate intervention? "An antidote will be given in juice." "IV fluids will be given." "Charcoal will be placed into the stomach." "A chelating agent will be given." 19 A child admitted for acute nephrotic syndrome has been receiving prednisone by mouth for the past week. After reviewing the child's laboratory results, which of the following findings should the nurse report to the primary care provider? Serum sodium of 142 mEq/L Serum potassium of 4.0 mEq/L White blood cell count of 3,000/mm3 Platelet count of 298,000/mm3 20 A nurse is providing discharge teaching to the parent of a child who experienced status asthmaticus. Which of the following responses by the parent indicates an understanding of the teaching? “I will perform chest physiotherapy during an acute attack.” “When using a metered-dose inhaler, my child should inhale then quickly exhale the medication." "My child will use his bronchodilator before bedtime to prevent wheezing." “I will call the doctor if my child becomes anxious and restless at night." 21 A nurse is assessing a toddler admitted with gastroenteritis. Which of the following assessments is the best indicator that the child is dehydrated? Skin turgor Capillary refill Heart rate Weight 22 A nurse is teaching postoperative colostomy care to the family of an infant with Hirschprung's disease. Which of the following statements by the family indicates a need for further teaching? "I will call the primary care provider if my infant has skin breakdown." "My infant's stoma should be pink and moist." "My infant's appliance has some room to move around." "My infant will wear a one-piece outfit to protect the bag." 23 A nurse is planning to change a toddler's tracheostomy ties. Which of the following actions by the nurse is the highest priority? Cut old tracheostomy ties after the new ties are in place. Use a soft and durable material for tracheostomy ties. Allow for a fingertip width between the neck and tracheostomy ties. Flex the toddler's neck while securing the tracheostomy ties. 24 An infant is admitted to the emergency department for an apparent life-threatening event. When assessing the infant, the nurse notes a respiratory rate of 8/min with a 25-second pause. Which of the following interventions should the nurse take first? Obtain information about the event. Call for help. Count the infant's heart rate. Check the infant's responsiveness. 25 A nurse is performing an assessment on an infant with heart failure. Which of the following assessment findings should the nurse expect? Temperature Increased urinary output Flushing of the skin Weak peripheral pulses 26 A child is receiving epidural analgesia following a surgical procedure. Which of the following is most important for the nurse to monitor? Peripheral pulses Urinary output Bowel sounds Gag reflex 27 A nurse is planning care for an adolescent following insertion of Harrington rods for treatment of scoliosis. Which of the following should the nurse include in the plan of care? Encourage the family to perform the adolescent’s personal care. Use a log rolling technique to change the adolescent’s position. Begin ambulation on the adolescent's first postoperative day. Administer pain medication per the adolescent’s request. 28 A 7-year-old child is 2 days postoperative following an appendectomy with rupture. A nasogastric tube set to low, intermittent suction is in place. Which of the following findings should indicate to the nurse that gastrointestinal function has returned? The nasogastric tube has 20 mL of output every hour. The child reports thirst and hunger. Bowel sounds are auscultated. The abdomen is soft and nondistended on palpation. 29 A nurse is providing postoperative care for a child following an arterial cardiac catheterization. Which of the following actions should the nurse take? Maintain the child's NPO status for 4 to 6 hr. Monitor output using an indwelling catheter for the first 24 hr. Keep the affected extremity straight for at least 6 hr. Remove the child's pressure dressing after the first 4 hr. 30 A nurse is caring for a school-age child who is experiencing pain. Which of the following assessment techniques will provide the most accurate information regarding the child's pain? Monitor the child’s involuntary movements. Assess the child’s pulse and respirations. Observe the child’s facial expressions. Ask the child to use a rating scale. 31 Which of the following assessment findings in an infant should indicate to a nurse that suctioning of the nasopharynx is needed? The infant is beginning to cough. The infant's respiratory rate is 30 to 32/min. The infant is becoming irritable. The infant's heart rate is 120 to 130/min. 32 A nurse is caring for a school-age child with nephrotic syndrome. Which of the following laboratory values should the nurse recognize as an expected finding for this child? Creatinine level of 1.6 mg/dL BUN level of 15 mg/dL Sodium level of 128 mg/dL Hgb level of 12 g/dL 33 A nurse is preparing to administer an opioid medication to a school-age child who rates his pain as a 7 on a scale of 0 to 10. Which of the following assessment findings has the highest priority? Hypoactive bowel sounds Respiratory rate of 10/min Nausea and vomiting Heart rate of 110/min 34 A parent brings her 6-month-old infant to the clinic for her scheduled immunizations. Which of the following reports by the parent regarding the child's last set of immunizations indicates that precautions should be considered? The infant was lethargic for 8 hr. The infant was unwilling to move her leg for 24 hr. The infant had an elevated temperature. The infant cried uncontrollably for 3 hr. 35 A nurse is performing CPR on an infant. Which of the following demonstrates correct technique? Perform compressions at 80 to 90/min. Deliver 3 breaths to every 30 compressions. Place two fingers on sternum one fingerbreadth below nipple line. Pinch nostrils while delivering breath through the mouth. 36 A school-age child has sustained a head injury and developed increased intracranial pressure. Which of the following vital signs should the nurse recognize as being consistent with increased intracranial pressure? A respiratory rate of 12 to 14/min A respiratory rate of 23 to 25/min A heart rate of 80/min A heart rate of 90/min 37 A nurse is planning to teach a health program about motor vehicle safety to a group of adolescents. Which of the following interventions best promotes learning in this age group? Provide pictures to illustrate the content. Give examples with decision-making options for discussion. Stress the hazards of drinking and drug use when driving. Appeal to the adolescents' sense of responsibility. 38 A nurse is preparing to administer immunizations to a 4-month-old infant who experienced redness and swelling with a previous injection. Which of the following interventions should the nurse take? Do not administer the vaccines. Administer the vaccines in divided doses. Administer a reduced dose of the vaccines. Administer the regular dose of the vaccines. 39 A nurse is called to the room of a child who is having a tonic-clonic seizure. To prevent injury to the child, which of the following actions should the nurse take? Turn the child onto her side. Administer an IM antiepileptic medication. Insert an oral airway. Begin rescue breathing. 40 An adolescent has just had a lumbar puncture. Which of the following nursing actions should the nurse take next? Elevate the head of the bed. Apply a dressing to the site. Medicate for pain. Monitor vital signs. 41 A nurse is caring for an infant with bronchiolitis. The infant's oxygen saturation reading is 88%. Which of the following actions should the nurse take first? Administer a nebulizer treatment. Sit the infant up. Notify the primary care provider. Suction the infant's nares. 42 Which of the following statements made by the mother of a child who just underwent surgical repair of cleft lip and palate indicates to the nurse a need for further teaching? "I will keep my baby in an upright position." "I will apply elbow restraints to my baby." "I will apply antibiotic ointment as prescribed." "I will let my baby keep her pacifier." 43 A nurse is caring for a school-age child with diabetes mellitus. Which of the following findings should the nurse recognize as being consistent with hyperglycemia? Thirst Pallor Headache Tremors 44 For which of the following child laboratory values should a nurse contact the primary care provider? A school-age child with cystic fibrosis with an HCO3- of 24 mEq/L A child with suspected lead poisoning who has a lead level of 15 ug/dL An adolescent with type 1 diabetes mellitus with an HbA1c of 5% A school-age child with renal failure who has a specific gravity of 1.005 45 An infant has been admitted for a pyloromyotomy. Preoperatively, a nasogastric tube (NG) is placed to low-intermittent suction. Which of the following nursing interventions should the nurse do if the NG tube is not draining? Flush the tube. Initiate continuous suction. Assess for placement. Clamp the tube. 46 A nurse is caring for four children. Which of the following is most at risk for impaired vascular perfusion? A child with a fractured radius A child with scoliosis A child with juvenile rheumatoid arthritis A child with a clubfoot 47 A nurse is assessing a preschooler in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings has the highest priority? The child's throat pain increases. The child refuses clear liquids. The child swallows frequently. The child cries often. 48 A nurse is providing teaching to the parents of a school-age child diagnosed with a seizure disorder. The parents are concerned that the child will have a seizure and they will not know what to do. Which of the following should the nurse include in the teaching? Remove hard objects close to the child. Place the child on his back during a seizure. Administer an extra dose of his medication. Insert a tongue blade between the child’s teeth. 49 A nurse is providing teaching regarding toilet training to a parent of a 16-month-old child. Which of the following statements made by the parent indicates an understanding of the teaching? "My child is ready to toilet train now." "My child must be able to remove his clothing to train." "It's okay for my child to get on and off the toilet during training." "My child will need a free-standing potty chair to begin training." 50 A nurse is caring for a child who is in skeletal traction for a fractured tibia. Which of the following is an appropriate intervention for the nurse to take? Permit the child to choose a comfortable position. Release the traction briefly for repositioning. Allow the weights to rest on the floor. Promote active range of motion to unaffected joints. 51 A nurse is caring for a child who ingested a large amount of acetaminophen (Tylenol) 6 days ago. Which of the following are expected findings in the late stage of acetaminophen poisoning? Abdominal pain and jaundice Tinnitus and tachypnea Hematemesis and bloody stools Paralysis and seizures 52 A preschooler who has just returned from cardiac catheterization experiences bleeding at the site. Which of the following nursing interventions should the nurse implement? Reinforce the dressing. Apply a 5 lb sandbag to the site. Elevate the head of the bed to a 45 degree angle. Apply direct pressure 1 inch above the site. 53 A nurse is interviewing the parent of a school-age child with asthma. Which of the following statements by the parent indicates to the nurse a need for further teaching? "My child uses fluticasone propionate (Flovent) with a spacer daily." "My child uses albuterol (Proventil) once a day." "My child is currently using montelukast (Singulair) at bedtime." "My child uses cromolyn sodium (Intal) before going to gym class." 54 An infant is brought by her parents to the clinic for a 6-month check up. During the assessment, the nurse instructs the parents that their infant's next immunization will occur at 8 months. 10 months. 12 months. 24 months. 55 A toddler diagnosed with tetralogy of Fallot becomes hyperpneic with worsening cyanosis. Which of the following actions should the nurse take first? Place the toddler in the knee-chest position. Start IV fluid replacement. Provide 100% oxygen by face mask. Administer morphine sulfate. 56 A nurse is providing teaching to the parents of an infant with failure to thrive. Which of the following should the nurse include in the teaching? Hold the infant face-to-face to maintain eye contact. Alternate feedings between several family members. Introduce several new foods to stimulate the infant’s interest. Provide a stimulating environment to keep the infant awake. 57 A nurse is assessing the growth and development of an early school-age child. Which of the following indicates achievement of psychosocial development? The child expresses a need to belong to a club. The child develops an understanding of grammar. The child develops his own rules for board games. The child expresses pride in his report card. 58 An infant is admitted to the hospital for pertussis. The nurse recognizes that following recovery from his illness the infant will exhibit which of the following types of immunity? Natural active Natural passive Artificial active Artificial passive 59 The family of a child diagnosed with attention deficit hyperactivity disorder requests information regarding management of the child's disorder. Which of the following techniques should the nurse suggest? Require the child to keep his bedroom clean. Use a chart to organize daily activities. Keep the child busy with multiple projects. Present the child with numerous choices when picking snacks. 60 Which of the following factors predisposes an infant to abuse? Premature birth Early walking Poor eater Gender 61 A nurse has finished assisting a primary care provider with a jugular venipuncture on a child with iron-deficiency anemia. For how long should the nurse expect to apply digital pressure to the site to stop the bleeding? 1 to 2 min 3 to 5 min 6 to 8 min 9 to 10 min 62 A nurse is planning a class for parents regarding managing an infestation of lice in school-age children. Which of the following instructions should a nurse include in the teaching? Bag the child’s nonwashable items and discard. Monitor the child's scalp for 2 to 3 days. Apply medication twice daily until symptoms subside. Remove nits from hair using a fine-tooth comb. 63 A toddler is admitted to the hospital with gastroenteritis positive for rotavirus. For which of the following activities should the nurse wear a gown and don gloves? Delivering the food tray Administering medication Changing the bed linens Assessing the IV site 64 Which of the following behaviors should a nurse teach a family to expect in their toddler who was admitted to the pediatric unit? Ritualism Regression Dethronement Aggression 65 A nurse is performing a developmental assessment on a 3 year old during a well- child visit. Which of the following findings should the nurse expect to observe in this child? Jumps rope Ties his shoes Walks heel to toe Draws a circle

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