ATI RN
Nursing Care of Children Final ATI
1. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?
- A. It is best to wait until the child asks about it.
- B. The best time to tell the child is between the ages of 7 and 10 years.
- C. It is not necessary to tell a child who was adopted so young.
- D. Telling the child is an important aspect of their parental responsibilities.
Correct answer: D
Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.
2. Patients with kidney stones should increase their intake of:
- A. fluids
- B. vitamin C
- C. oxalates
- D. protein
Correct answer: A
Rationale: Patients with kidney stones should increase their intake of fluids. Increasing fluid intake helps to dilute the urine and reduce the risk of kidney stones forming by flushing out minerals that can crystallize. This promotes the passage of small stones and helps prevent the formation of new ones. Vitamin C and protein intake should be moderated as excessive consumption may lead to the formation of certain types of kidney stones. Oxalates should be limited in the diet as they can contribute to the formation of calcium oxalate stones, a common type of kidney stone.
3. A client with neuropathic pain has a new prescription for amitriptyline once per day. What should the nurse include in the teaching?
- A. Take the medication with meals
- B. Increase fluids while on this medication
- C. Take it only at night
- D. Report any yellowing of the skin
Correct answer: B
Rationale: The correct answer is B: 'Increase fluids while on this medication.' Amitriptyline can cause side effects like dry mouth and urinary retention. Increasing fluids can help alleviate these side effects. Choices A, C, and D are incorrect. Taking the medication with meals or only at night is not specifically related to managing the side effects of amitriptyline. Reporting yellowing of the skin is important but not directly related to the side effects of this medication.
4. How should fluid overload in a patient with heart failure be managed?
- A. Administer diuretics
- B. Increase fluid intake
- C. Provide oral fluids
- D. Provide chest physiotherapy
Correct answer: A
Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.
5. Which clinical manifestation should a nurse monitor for when assessing a pediatric client diagnosed with a basilar skull fracture?
- A. Periorbital ecchymosis
- B. Subdural hematoma
- C. Protruding bone
- D. Epidural hematoma
Correct answer: A
Rationale: Periorbital ecchymosis, also known as raccoon eyes, is a classic sign of a basilar skull fracture. It presents as bruising around the eyes due to blood collecting in the tissues. Monitoring for periorbital ecchymosis is crucial in assessing a pediatric client with a basilar skull fracture because it can indicate the presence of this serious injury.
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