ATI RN
RN Nursing Care of Children 2019 With NGN
1. A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis during this acute phase to show?
- A. Bacteriuria and hematuria
- B. Hematuria and proteinuria
- C. Bacteriuria and increased specific gravity
- D. Proteinuria and decreased specific gravity
Correct answer: B
Rationale: Hematuria (blood in the urine) and proteinuria (protein in the urine) are common findings in acute glomerulonephritis due to inflammation of the glomeruli. Bacteriuria and changes in specific gravity are not as directly associated with this condition.
2. What measure of fluid balance status is most useful in a child with acute glomerulonephritis?
- A. Proteinuria
- B. Daily weight
- C. Specific gravity
- D. Intake and output
Correct answer: B
Rationale: Daily weight is the most accurate measure of fluid balance in children with acute glomerulonephritis, as it reflects changes in body fluid status more reliably than other measures like proteinuria or specific gravity.
3. What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?
- A. Teaching how to irrigate the colostomy
- B. Protecting the skin around the colostomy
- C. Discussing the implications of a colostomy during puberty
- D. Using simple, straightforward language to prepare the child
Correct answer: B
Rationale: Protecting the skin around the colostomy is crucial to prevent irritation and infection, which are common complications in infants with colostomies. Teaching and discussing long-term implications are important but secondary to immediate skin care needs.
4. The LPN is assessing for fontanels on the head of a 6-month-old. Which fontanel is expected to still be present?
- A. Posterior
- B. Anterior
- C. Sphenoid
- D. Lambdoid
Correct answer: B
Rationale: The correct answer is B: Anterior. The anterior fontanel usually remains open until about 12-18 months of age, while the posterior fontanel closes by 2-3 months. Choices A, C, and D are incorrect as the posterior fontanel closes by 2-3 months of age, and the sphenoid and lambdoid fontanels are not typically assessed in routine infant head examinations.
5. A child with acetylsalicylic acid (aspirin) poisoning is being admitted to the emergency department. What early clinical manifestation does the nurse expect to assess on this child?
- A. Hematemesis
- B. Hematochezia
- C. Hyperglycemia
- D. Hyperventilation
Correct answer: D
Rationale: Early signs of aspirin poisoning include hyperventilation due to the stimulation of the respiratory center and the resultant respiratory alkalosis. Hematemesis, hematochezia, and hyperglycemia can occur later in the poisoning process or may not be directly related to aspirin toxicity.
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