ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?
- A. Fear of strangers
- B. Minimal smiling
- C. Avoidance of eye contact
- D. All of the above
Correct answer: D
Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.
2. An RN is explaining to a student nurse what professionalism in nursing means. Which of the following statements, if made by the student nurse, demonstrates teaching has been successful?
- A. Commitment to others means I should be honest and accountable for my actions.
- B. I should encourage my fellow nurses to talk when they are having a bad day.
- C. I should be flexible with myself and my fellow nurses when it comes to the dress code.
- D. If I need a day off, I should promptly call in sick to give my manager plenty of time to find a replacement.
Correct answer: A
Rationale: Commitment to others involves accountability for one�s actions, lifelong learning, and commitment to colleagues.
3. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which action should the nurse take?
- A. Offer fluids every 2 hours.
- B. Document the client's behavior prior to being placed in seclusion.
- C. Discuss with the client their inappropriate behavior prior to seclusion.
- D. Assess the client's behavior every hour.
Correct answer: B
Rationale: The correct answer is to document the client's behavior prior to seclusion. Documenting the behavior is crucial as it helps justify the need for seclusion, provides a clear record of events leading up to the intervention, and ensures transparency in the client's care. Offering fluids every 2 hours (Choice A) is important for hydration but is not directly related to the situation of seclusion. Discussing the inappropriate behavior with the client (Choice C) may not be safe or appropriate when seclusion is necessary for preventing harm. Assessing the client's behavior every hour (Choice D) is important but may not be the most immediate action needed when seclusion is already in place.
4. A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?
- A. Let's talk about how you can change your response to stress.
- B. We should establish our roles in the initial session.
- C. Let me show you simple relaxation exercises to manage stress.
- D. We should discuss resources to implement in your daily life.
Correct answer: B
Rationale: During the orientation phase of the therapeutic relationship, it is crucial to establish roles. This helps both the client and the nurse understand their responsibilities, boundaries, and expectations within the therapeutic process. Choice A is more focused on the working phase where strategies and interventions are discussed. Choice C is more suitable for the working phase where specific techniques are usually introduced. Choice D is also more relevant to the working phase as it involves discussing practical resources for implementation in daily life.
5. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct answer: D
Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.
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