ATI RN
RN Pediatric Nursing 2023 ATI
1. A healthcare professional is assessing a child who has a rotavirus infection. Which of the following is an expected manifestation?
- A. Constipation
- B. Vomiting
- C. Jaundice
- D. Abdominal pain
Correct answer: B
Rationale: Vomiting is a common manifestation of rotavirus infection in children. Rotavirus typically presents with symptoms such as watery diarrhea, vomiting, fever, and abdominal pain. Constipation, jaundice, and abdominal pain are less commonly associated with rotavirus infection in children.
2. Which statement most reflects the observation that the infant sleeps soundly, awakens on his own, and maintains a quiet alert state?
- A. This is atypical behavior and should be addressed
- B. The infant should remain on high alert when awake
- C. This shows the infant is making neurological gains
- D. The family is disrupting the child's sleep patterns
Correct answer: C
Rationale: A quiet alert state in infants indicates positive neurological development. It showcases the infant's ability to regulate sleep-wake cycles and maintain an optimal state for learning and interaction. Therefore, observing an infant who sleeps soundly, awakens on his own, and stays in a quiet alert state is a reassuring sign of neurological gains and healthy development. Choice A is incorrect as it misinterprets normal behavior as atypical. Choice B is incorrect as it suggests the infant should be on high alert, which is not developmentally appropriate. Choice D is incorrect as it falsely blames the family for disrupting the child's sleep patterns, whereas the scenario described indicates positive neurological growth.
3. A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?
- A. Hypotonia and muscle instability
- B. Hypertonia and persistence of primitive reflexes
- C. Tremors and exaggerated posturing
- D. Hemiplegia and hypertonia
Correct answer: A
Rationale: In ataxic cerebral palsy, the characteristic features include hypotonia (low muscle tone) and muscle instability. These manifestations contribute to the infant's difficulty in achieving independent sitting. Hypertonia (increased muscle tone) and persistence of primitive reflexes, as mentioned in option B, are more commonly associated with other types of cerebral palsy like spastic CP. Tremors and exaggerated posturing (option C) are not typical features of ataxic CP. Hemiplegia (paralysis of one side of the body) and hypertonia (increased muscle tone) mentioned in option D are more commonly seen in other types of cerebral palsy, such as spastic CP.
4. A child is being assessed for possible appendicitis with perforation. Which of the following findings should the nurse expect?
- A. Hyperactive bowel sounds
- B. Abdominal distension
- C. Hypoactive bowel sounds
- D. Bradycardia
Correct answer: D
Rationale: In a child with appendicitis and possible perforation, the nurse should expect bradycardia due to peritoneal irritation. Bradycardia is a common response to peritoneal inflammation or infection, indicating a possible serious complication. Hyperactive bowel sounds, abdominal distension, and hypoactive bowel sounds are more commonly associated with other gastrointestinal conditions and are less likely to be present in a child with appendicitis and perforation. Therefore, the correct answer is bradycardia (D) as it aligns with the expected physiological response in this scenario.
5. A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN). Which is the priority nursing diagnosis for this child?
- A. Risk for Injury related to hypertension.
- B. Altered Growth and Development related to chronic disease.
- C. Risk for Infection related to hypertension.
- D. Fluid Volume Excess related to decreased plasma filtration.
Correct answer: A
Rationale: The priority nursing diagnosis for a preschool-age child with acute postinfectious glomerulonephritis (APIGN) is 'Risk for Injury related to hypertension' due to the potential complications such as hypertensive encephalopathy. Hypertension poses an immediate threat to the child's well-being, making it crucial to address the risk for injury associated with elevated blood pressure as the top priority.
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