ATI RN
RN Nursing Care of Children 2019 With NGN
1. A child is refusing to use the potty and having accidents, even though he has achieved toilet training. This is an example of which type of behavior?
- A. Positive reinforcement
- B. Desensitization
- C. Phobia
- D. Regression
Correct answer: D
Rationale: The correct answer is D, regression. Regression occurs when a child reverts to an earlier behavior, such as having accidents after being successfully toilet trained. This regression often happens due to stress or changes in routine. Choices A, B, and C are incorrect because positive reinforcement involves encouraging desired behavior, desensitization is a process of reducing sensitivity to a stimulus, and phobia is an intense fear or aversion to a specific object or situation, none of which directly apply to the described situation of the child having accidents after being toilet trained.
2. When instructing a client with a new prescription for Timolol on how to insert eye drops, which area should the nurse instruct the client to press on to prevent systemic absorption of the medication?
- A. Bony orbit
- B. Nasolacrimal duct
- C. Conjunctival sac
- D. Outer canthus
Correct answer: B
Rationale: Pressing on the nasolacrimal duct, located near the inner corner of the eye, blocks the lacrimal punctum and prevents the medication from entering the systemic circulation. This technique helps to ensure the medication stays localized in the eye, enhancing its therapeutic effect while minimizing systemic side effects. Choices A, C, and D are incorrect. The bony orbit is the eye socket and not a site to press for preventing systemic absorption. The conjunctival sac is where eye drops are instilled, not pressed on. The outer canthus is also not the correct area to press to prevent systemic absorption.
3. A nurse is assessing a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 62/min
- B. Blood pressure of 118/78 mm Hg
- C. Respiratory rate of 10/min
- D. Pain rating of 4 on a scale of 0 to 10
Correct answer: C
Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within normal limits and are not indicative of a potentially life-threatening complication associated with morphine therapy.
4. During pregnancy, a woman is in a relationship with a male who routinely abuses her. Her unborn child may engage in high-risk behavior as a teen as a result of:
- A. Maternal stress
- B. Parental nurturing
- C. Appropriate stress responses in the brain
- D. Memories of the abuse
Correct answer: A
Rationale: Maternal stress during pregnancy can have long-term effects on the child's behavior and stress responses. Research shows that exposure to high levels of stress hormones in the womb can influence the developing fetal brain and the child's future behavior, potentially leading to high-risk behaviors during adolescence.
5. A client with heart failure is receiving furosemide. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min.
- B. Weight loss of 1.1 kg (2.5 lb) in 24 hours.
- C. Potassium level of 3.8 mEq/L.
- D. Urine output of 60 mL/hr.
Correct answer: B
Rationale: A weight loss of 1.1 kg (2.5 lb) in 24 hours may indicate dehydration or fluid imbalance, which should be reported. This rapid weight loss could be a sign of excessive diuresis, potentially leading to hypovolemia or electrolyte imbalances. Monitoring weight changes is crucial in clients with heart failure receiving diuretics. The other findings are within normal ranges and expected in a client receiving furosemide for heart failure. A heart rate of 80/min, a potassium level of 3.8 mEq/L, and a urine output of 60 mL/hr are generally acceptable in this scenario.