ATI- Nursing Care of Children

ATI- Nursing Care of Children Drawing, painting, riding a tricycle - CORRECT ANSWER-preschoolers Banging large block - CORRECT ANSWER-9 - 12 months Team sports - CORRECT ANSWER-school-aged Watching black-and-white mobiles - CORRECT ANSWER-Birth to 3 months Playing peek-a-boo - CORRECT ANSWER-6 to 9 months Holding a soft rattle - CORRECT ANSWER-3 to 6 months Loud, harsh murmur; Mild heart failure; Possible enlarged right atrium; Increased oxygen saturations in the right atrium; Asymptomatic (possibly). - CORRECT ANSWERAtrial septal defect (ASD) Increased blood pressure and oxygen saturation in the upper extremities compared to the lower extremities; Nosebleeds; Headaches, vertigo, leg pain, weak or absent lower extremity pulses (indicate decreased cardiac output). - CORRECT ANSWERCoarctation of the aorta Murmur (machine-hum); Wide pulse pressure; Bounding pulses; Asymptomatic (possibly) - CORRECT ANSWER-Patent ductus arteriosus (PDA) Systolic ejection murmur; Right ventricular enlargement; Exercise intolerance; Cyanosis with severe narrowing. - CORRECT ANSWER-Pulmonary stenosis Loud, harsh murmur that is not usually audible until pulmonary pressures drop at about 4 to 8 weeks of age; Heart failure; Failure to thrive; Small, possibly asymptomatic defects. - CORRECT ANSWER-Ventricular septal defect (VSD) Murmur; Cyanosis, severe dyspnea, clubbing of the fingers, hypercyanotic spells, and acidosis; Polycythemia, clot formation; Frequently sits in a squatting position (decreases venous return); Failure to thrive and growth retardation - CORRECT ANSWERTetralogy of Fallot May have difficulty accepting death because they are discovering who they are, establishing an identity, and dealing with issues of puberty. - CORRECT ANSWERAdolescents Experience fear of the disease process, the death process, the unknown, and loss of control - CORRECT ANSWER-School-age children Have egocentric thinking that prevents them from understanding death. - CORRECT ANSWER-Toddlers View dying as temporary because they have no concept of time and because the dead person may still have attributes of the living (sleeping, eating, breathing). - CORRECT ANSWER-Preschool A nurse is caring for a 6-month-old infant following surgery. Which of the following should the nurse use to measure pain in this client? a. FLACC pain scale. b. There is no special pain scale for infants. c. Wong-Baker faces pain rating scale. d. Oucher numeric scale. - CORRECT ANSWER-a. FLACC pain scale. A nurse is caring for an infant following a cleft lip and palate repair. Which of the following actions should the nurse take in the post-operative period? Select one: a. Encourage the use of a pacifier. b. Assess incision using tongue blade. c. Provide hard toys. d. Administer analgesics. - CORRECT ANSWER-d. Administer analgesics. The nurse should keep the infant pain-free to decrease crying and stress on the repair. A nurse is caring for a child with a closed head injury. Which of the following interventions should the nurse institute to decrease intracranial pressure? Select all that apply. Select one or more: a. Instruct to avoid coughing and blowing nose. b. Keep the head of the bed flat. c. Provide a calm, restful environment. d. Avoid extreme flexion, extension or rotation of the head. e. Keep the body in alignment. - CORRECT ANSWER-Avoid extreme flexion, extension or rotation of the head., Keep the body in alignment., Instruct to avoid coughing and blowing nose., Provide a calm, restful environment. Which of the following is the priority intervention a nurse should take when caring for a child who just experienced a febrile seizure? Select one: a. Check for injuries. b. Reorient to the environment. c. Keep in a side-lying position. d. Take vital signs. - CORRECT ANSWER-c. Keep in a side-lying position. The greatest risk for the child is aspiration. Therefore, the priority intervention during the postictal phase is to keep the child in a side-lying position so secretions can drain from the mouth. The other interventions are important, but they are not the priority at this time. A nurse is providing discharge education to the parents of a child experiencing acute diarrhea secondary to gastroenteritis. Which of the following should the nurse include? Select one: a. Provide fruit juices throughout the day. b. Provide chicken or beef broth throughout the day. c. Use prepared oral replacement solutions (ORS). d. Use the BRAT (bananas, rice, applesauce and toast) diet. - CORRECT ANSWER-c. Use prepared oral replacement solutions (ORS). A school nurse is providing education to a child's mother regarding head lice. Which of the following should the nurse include? Select one: a. Lice and nits do not survive away from a host. b. Your child cannot get lice if their hair is kept clean. c. Children should be instructed to not share hats or combs. d. It is very easy to catch lice as they can jump from head to head. - CORRECT ANSWER-c. Children should be instructed to not share hats or combs. Lice are transmitted by contact such as via personal items like hats and combs. A nurse is caring for a 6-month-old client who has sudden abdominal pain, vomiting, distended abdomen and red current jelly-like stools. The nurse should know that these are signs for which of the following? Select one: a. Intussusception. b. Appendicitis. c. Pyloric stenosis. d. Hernia. - CORRECT ANSWER-a. Intussusception. Intussusception is the telescoping of the intestine over itself. This usually occurs in infants and young children up to 5 years of age, but it is most common between 5 and 9 months of age. Manifestations include: • Normal comfort interrupted by periods of sudden and acute pain • Palpable, sausage-shaped mass in the right upper quadrant of the abdomen and/or a tender, distended abdomen