a child with acute gastrointestinal bleeding is admitted to the hospital the nurse observes which sign or symptom as an early manifestation of shock
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

2. Which is usually the only symptom of pediculosis capitis (head lice)?

Correct answer: A

Rationale: Itching is typically the primary and most common symptom of pediculosis capitis due to the lice bites on the scalp.

3. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

Correct answer: A

Rationale: Vesicular breath sounds are normally heard over most of the lung fields, except near the trachea and main bronchi, where bronchial or bronchovesicular sounds may be heard.

4. What is a common cause of acquired aplastic anemia in children?

Correct answer: B

Rationale: The correct answer is B. Acquired aplastic anemia in children is often caused by exposure to certain drugs, such as chloramphenicol or antiepileptics, which can lead to bone marrow failure and a decrease in all types of blood cells. Choices A, C, and D are incorrect because aplastic anemia is not commonly caused by deficient diet, congenital defects, or injury in children.

5. The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?

Correct answer: D

Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.

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