ATI RN
Nursing Care of Children Final ATI
1. A 5-year-old is hospitalized with a fractured femur. Which pain assessment tool is appropriate for this child?
- A. CRIES Scale
- B. Faces Pain Rating Scale
- C. SUN Scale
- D. NIPS Scale
Correct answer: B
Rationale: The Faces Pain Rating Scale is appropriate for assessing pain in children who can express their feelings visually. For a 5-year-old child who can communicate effectively, using a tool like the Faces Pain Rating Scale, which uses facial expressions to indicate pain levels, is more suitable than the CRIES Scale (used for neonates), the SUN Scale (used for infants), or the NIPS Scale (used for preterm and term newborns).
2. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?
- A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
- B. Risk for aspiration related to feeding the infant an inappropriate food
- C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
- D. Readiness for enhanced nutrition, related to the age of the infant
Correct answer: B
Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.
3. The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?
- A. The child may think the equipment is alive.
- B. Explaining the equipment will only increase the child’s fear
- C. One brief explanation will be enough to reduce the child’s fear
- D. The child is too young to understand what the equipment does
Correct answer: A
Rationale: Preschoolers may engage in magical thinking and believe inanimate objects are alive, so the nurse should explain the equipment in a way that reduces fear.
4. What is the primary consideration of susceptibility to infections in neonates?
- A. Increased humoral immunity
- B. Overwhelming anti-inflammatory response
- C. Diminished nonspecific and specific immunity
- D. Excessive levels of immunoglobulin A and immunoglobulin M
Correct answer: C
Rationale: The primary consideration of susceptibility to infections in neonates is their diminished nonspecific and specific immunity. Neonates lack the ability to mount a robust immune response, making them vulnerable to infections. Choice A is incorrect because neonates do not have increased humoral immunity; rather, their humoral immunity is diminished. Choice B is incorrect as neonates do not have an overwhelming anti-inflammatory response; instead, their immune responses are generally weakened. Choice D is incorrect because neonates have diminished or absent levels of immunoglobulin A and immunoglobulin M, contributing to their susceptibility to infections.
5. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning?
- A. Purposeful and goal-directed
- B. A simple developmental process
- C. Based on deliberate and irrational thought
- D. Assists individuals in guessing what is most appropriate
Correct answer: A
Rationale: Clinical reasoning is purposeful and goal-directed, involving the use of critical thinking and decision-making skills to provide effective patient care.