ATI RN
Nursing Care of Children ATI
1. A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?
- A. Monitor blood pressure every 30 minutes.
- B. Reposition the child every two hours.
- C. Limit visitors.
- D. Encourage fluids.
Correct answer: B
Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.
2. A parent and 4-year-old child are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the child doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?
- A. Reading a book
- B. Singing a song he learned at preschool
- C. Opening drawers in the room, pulling out supplies, and examining them
- D. Roughhousing with the parent
Correct answer: C
Rationale: The correct answer is C. According to Erikson, the primary task of a preschool-aged child is to explore and assert control over their environment. This behavior is demonstrated by the child opening drawers, pulling out supplies, and examining them, showcasing curiosity and exploration. Choices A, B, and D do not align with the primary developmental task of a preschool-age child according to Erikson. Reading a book and singing a song are more passive activities, while roughhousing with the parent does not directly relate to exploration and asserting control over the environment.
3. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?
- A. Explain that it will not be painful.
- B. Suggest to him that he not worry about losing just a little bit of blood.
- C. Discuss with him how his body is always in the process of making blood.
- D. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.
Correct answer: C
Rationale: Discussing how the body continuously makes blood helps the child understand that losing a small amount is normal and not harmful. This educational approach also helps reduce anxiety by giving the child a sense of control over the situation.
4. The LPN is caring for a 1-month-old patient post-surgery. Which pain scale is expected to be used to evaluate post-op pain?
- A. Oucher
- B. Wong-Baker FACES
- C. FLACC
- D. 0-10 pain scale
Correct answer: C
Rationale: The FLACC (Face, Legs, Activity, Cry, Consolability) scale is commonly used to assess pain in infants and young children who are unable to verbally communicate their pain. This scale is particularly useful in assessing post-operative pain in infants as it evaluates different behaviors and physiological responses to pain. The Oucher scale is more commonly used with children who are older and can provide self-report of pain intensity. Wong-Baker FACES scale is primarily used with children who are older and can indicate their pain level by pointing to facial expressions. The 0-10 pain scale is typically used with older children and adults who can rate their pain on a numerical scale.
5. According to Maslow’s hierarchy, what is the most advanced need provided by the home environment?
- A. Love
- B. Self-actualization
- C. Esteem
- D. Physiological
Correct answer: B
Rationale: The correct answer is B, self-actualization. Self-actualization is the highest level in Maslow's hierarchy of needs, representing the realization of one's full potential. While love is an essential need, self-actualization builds upon the fulfillment of basic needs like safety and love. Esteem needs relate to feelings of accomplishment and recognition, which come before self-actualization. Physiological needs such as food, water, and shelter are the most basic needs at the bottom of the hierarchy.
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