ATI RN
RN Nursing Care of Children 2019 With NGN
1. A 14-month-old child is admitted to the hospital with laryngotracheobronchitis (LTB). Which assessment findings should the nurse expect?
- A. Cyanosis and dyspnea
- B. Productive cough and high fever
- C. Barking cough and inspiratory stridor
- D. Pale laryngeal and dyspnea
Correct answer: C
Rationale: The correct answer is C: 'Barking cough and inspiratory stridor.' Classic signs of laryngotracheobronchitis (LTB) include a barking cough, often described as a seal-like cough, and inspiratory stridor, which is a high-pitched sound heard during inspiration. These symptoms occur due to inflammation and narrowing of the upper airway. Choices A, B, and D are incorrect as they do not align with the typical assessment findings of LTB. Cyanosis and dyspnea (Choice A) may occur in severe cases but are not specific to LTB. Productive cough and high fever (Choice B) are more indicative of lower respiratory tract infections. Pale laryngeal and dyspnea (Choice D) are not characteristic findings of LTB.
2. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?
- A. Check the urine to see if hematuria has increased.
- B. Obtain the child's blood pressure and notify the healthcare provider.
- C. Obtain serum electrolytes and send urinalysis to the laboratory.
- D. Reassure the child and encourage bed rest until the headache improves.
Correct answer: B
Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.
3. Which characteristic best describes the fine motor skills of an infant at age 5 months?
- A. Neat pincer grasp
- B. Strong grasp reflex
- C. Builds a tower of two cubes
- D. Able to grasp object voluntarily
Correct answer: D
Rationale: By 5 months, infants develop the ability to grasp objects voluntarily, showing improved motor control. The neat pincer grasp and building towers are skills that develop later.
4. What illnesses does respiratory hygiene and cough etiquette by the Centers for Disease Control and Prevention (CDC) prevent?
- A. HBV, Hib, and pertussis
- B. HSV, influenza, and HBV
- C. RSV, influenza, and adenovirus
- D. RSV, pertussis, and varicella
Correct answer: C
Rationale: The correct answer is C: RSV, influenza, and adenovirus. The CDC recommends respiratory hygiene and etiquette to prevent the transmission of respiratory syncytial virus (RSV), influenza, adenovirus, and other droplet-transmitted unknown viruses. Choices A, B, and D are incorrect because HBV, Hib, pertussis, HSV, and varicella are not typically transmitted via droplets but through other modes of transmission.
5. Ongoing fluid losses can overwhelm the child’s ability to compensate, resulting in shock. What early clinical sign precedes shock?
- A. Tachycardia
- B. Slow respirations
- C. Warm, flushed skin
- D. Decreased blood pressure
Correct answer: A
Rationale: Tachycardia is an early sign of shock as the body tries to maintain cardiac output in the face of declining circulatory volume. Blood pressure often remains normal until late in the progression, at which point decompensated shock is occurring.
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