ATI RN
ATI Nursing Care of Children
1. A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?
- A. Restate what the physician has told her about plastic surgery
- B. Suggest holding her baby without making eye contact
- C. Encourage and allow the mother to express her feelings
- D. Recognize and allow the mother to express her feelings
Correct answer: D
Rationale: In this situation, the priority is to acknowledge and validate the mother's feelings, creating a supportive environment for her. Option D is correct as it focuses on recognizing and allowing the mother to express her emotions. This approach can help build trust and facilitate communication. Options A and B are incorrect as they do not address the mother's emotional needs and may come across as dismissive. Option C is less appropriate as it only encourages expression without explicitly recognizing the mother's current emotional state.
2. A client is planning eating strategies with a nurse who has nausea from equilibrium imbalance. Which of the following strategies should the nurse recommend?
- A. Encourage the client to eat, even if nauseated.
- B. Provide low-fat carbohydrates with meals.
- C. Limit fluid intake between meals.
- D. Serve hot foods at mealtime.
Correct answer: B
Rationale: The correct answer is B: Provide low-fat carbohydrates with meals. Low-fat carbohydrates are easier to digest and can help manage nausea without overloading the digestive system. Encouraging the client to eat even if nauseated (Choice A) may worsen their symptoms. Limiting fluid intake between meals (Choice C) may lead to dehydration, which can exacerbate nausea. Serving hot foods at mealtime (Choice D) may not necessarily address the underlying issue of equilibrium imbalance causing nausea.
3. What is a blood clot that forms in a vein, often in the legs, and can cause serious complications if it travels to the lungs?
- A. Deep vein thrombosis (DVT)
- B. Pulmonary embolism
- C. Varicose veins
- D. Atherosclerosis
Correct answer: A
Rationale: The correct answer is Deep vein thrombosis (DVT). DVT is a blood clot that forms in a deep vein, typically in the legs, and can lead to serious complications if it breaks loose and travels to the lungs, causing a pulmonary embolism. Varicose veins (choice C) are enlarged, twisted veins usually found in the legs but are not related to blood clots. Atherosclerosis (choice D) is a condition where arteries become narrowed and hardened due to a buildup of plaque, not directly related to blood clots.
4. Is the following statement true: The anatomical position is lying down, as a cadaver would be positioned?
- A. True
- B. False
- C. Not Sure
- D. None of the above
Correct answer: False
Rationale: The correct answer is False. The anatomical position is a standardized way of describing the human body's orientation in a consistent manner. The anatomical position is standing upright, facing forward, with the arms at the sides and palms facing forward. This position serves as a reference point for anatomical descriptions and directional terms. Therefore, the statement that the anatomical position is lying down, as a cadaver would be positioned, is incorrect. Choice A is incorrect because the anatomical position is not lying down. Choices C and D are also incorrect as there is a definitive answer to the question.
5. A client is receiving treatment with irinotecan. Which of the following findings should the nurse monitor?
- A. Diarrhea
- B. Hypertension
- C. Ototoxicity
- D. Neutropenia
Correct answer: A
Rationale: Corrected Rationale: Irinotecan is known to commonly cause diarrhea as an adverse effect due to its impact on the gastrointestinal tract. Therefore, the nurse should closely monitor the client for signs of diarrhea while receiving this treatment. Choices B, C, and D are incorrect because irinotecan is not typically associated with hypertension, ototoxicity, or neutropenia as primary adverse effects. While these side effects can occur with other medications, they are not the main concerns when monitoring a client receiving irinotecan.