ATI RN
ATI Nursing Care of Children
1. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
- A. Ask the parent when the neck was injured
- B. Refer for immediate medical evaluation
- C. Continue assessment to determine the cause of the neck pain
- D. Record head lag on the assessment record and continue the assessment of the child
Correct answer: B
Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.
2. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct answer: D
Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.
3. A nurse is carrying on a conversation with a 7-year-old child during an office visit. Which is an example of the level of language development the nurse should expect in this child?
- A. Fascination with bathroom language
- B. Difficulty understanding the concept of 'half past' in reference to time
- C. Ability to carry on an adult conversation
- D. Inability to speak in full sentences
Correct answer: B
Rationale: The correct answer is B. Understanding time concepts like 'half past' can be challenging for a 7-year-old, indicating the level of language development. Choice A is incorrect as fascination with bathroom language is common in this age group but not necessarily indicative of language development. Choice C is incorrect as a 7-year-old typically cannot carry on an adult conversation due to cognitive and experiential limitations. Choice D is incorrect as by the age of 7, children should be able to speak in full sentences.
4. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)
- A. Lightly brush the palate with a cotton swab
- B. Perform the examination in front of a mirror
- C. Let the child examine someone else's mouth first
- D. All of the above
Correct answer: D
Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.
5. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?
- A. Request a detailed listing of symptoms.
- B. Ask the adolescent, "Why did you come here today?"
- C. Interview the parent away from the adolescent to determine the chief complaint
- D. Use what the adolescent says to determine, in correct medical terminology, what the problem is
Correct answer: B
Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $149.99