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. An anxious 12-year-old child receives an injection from the nurse and sighs with relief when it is done. After a moment of reflection, the girl asks the nurse, 'Is it hard to give someone an injection?' This child’s question is evidence that the child has developed which cognitive skill?

Correct answer: C

Rationale: The correct answer is C: Decentering. Decentering is the ability to consider multiple aspects of a situation, which the child's question demonstrates. In this scenario, the child's question shows that she is thinking beyond her own experience and considering the difficulty or complexity of giving an injection from the nurse's perspective. Choices A, B, and D are incorrect. Conservation refers to understanding that certain properties of an object remain the same despite changes in its appearance. Accommodation is the process of adjusting existing knowledge or creating new mental categories to incorporate new information. Class inclusion involves understanding the relationship between a whole set and its subsets, which is not demonstrated in the child's question.

3. Which responsibilities are included in the pediatric nurse's promotion of the health and well-being of children? (Select all that apply.)

Correct answer: D

Rationale: Pediatric nurses promote health through disease prevention, support, counseling, therapeutic relationships, and participating in ethical decision-making.

4. Parents of a preschool child ask the nurse, "Should we set rules for our child as part of a discipline plan?" Which is an accurate response by the nurse?

Correct answer: D

Rationale: Clear and reasonable rules provide structure and help children understand expectations, promoting consistent behavior and discipline.

5. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?

Correct answer: A

Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.

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