ATI RN
Nursing Care of Children ATI
1. The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?
- A. Repression
- B. Regression
- C. Rationalization
- D. Fantasy
Correct answer: B
Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.
2. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?
- A. Encourage the child to blow the nose gently
- B. Notify the physician if mucus is observed in the emesis
- C. Position the child supine in the immediate postoperative period
- D. Avoid giving citrus juice
Correct answer: D
Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.
3. A child who weighs 10 kg is to receive Motrin 8 mg/kg po q4h prn for pain. The label reads 100 mg/5 mL. How much will you administer?
- A. 4 mL
- B. 2 mL
- C. 5 mL
- D. 3 mL
Correct answer: A
Rationale: To calculate the dosage, multiply the child's weight (10 kg) by the dosage (8 mg/kg) which equals 80 mg. Since the concentration is 100 mg/5 mL, to find out how much to administer, you need to determine how many 5 mL doses are in 80 mg. It will be 80 mg รท 100 mg * 5 mL = 4 mL. Therefore, the correct answer is 4 mL. Choice B, 2 mL, is incorrect because it does not account for the correct dosage calculation. Choice C, 5 mL, is incorrect as it does not consider the dosage based on the child's weight. Choice D, 3 mL, is incorrect as it does not reflect the accurate dosage calculation.
4. At which age can most infants sit steadily unsupported?
- A. 4 months
- B. 6 months
- C. 8 months
- D. 12 months
Correct answer: C
Rationale: Most infants can sit steadily without support by 8 months, indicating advanced gross motor skill development.
5. An important role of the nurse in ambulatory settings and schools is the identification of communicable diseases for treatment and the prevention of spread. What is an important component related to the first period of the contagiousness of disease?
- A. Source
- B. Causative agent
- C. Prodromal stage
- D. Constitutional symptoms
Correct answer: C
Rationale: The prodromal period is the interval between the early manifestations of the disease and the time when the overt clinical syndrome is evident. Most communicable diseases are contagious during this time. Identifying the prodromal stage is crucial for early intervention and preventing the spread of the disease. While the source and causative agent are important aspects of disease control, recognizing the early signs in the prodromal stage allows the nurse to take timely actions. Constitutional symptoms occur during the active disease phase, indicating that the child has already been contagious, and early intervention opportunities may have passed.
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