a preschool age boy presents to the outpatient clinic for a sore throat in the childs mind which is the most likely cause for the sore throat
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. A preschool-age boy presents to the outpatient clinic for a sore throat. In the child’s mind, which is the most likely cause for the sore throat?

Correct answer: D

Rationale: The correct answer is D. Preschool-age children often attribute illness to their actions, like yelling at a sibling or not following instructions. They may not understand medical causes such as exposure to infections like strep throat (choice A), dietary factors (choice B), or vitamin deficiencies (choice C). It is common for young children to connect symptoms to recent behaviors or events within their limited understanding.

2. Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

Correct answer: A

Rationale: The correct answer is A: Sitting independently. By 11 months, most infants can sit independently. This milestone usually precedes walking, which typically occurs closer to 12 months. Turning a doorknob and building a tower of four cubes involve more complex motor skills that are typically achieved later in development. Therefore, at 11 months, sitting independently is the milestone that the nurse would expect an infant to have achieved.

3. Which condition is most commonly associated with a 'sunset sign' in infants?

Correct answer: A

Rationale: The 'sunset sign,' characterized by downward-driven eyes, is most commonly associated with hydrocephalus. This condition causes increased intracranial pressure, leading to the eyes appearing to be forced downward. Meningitis (choice B) typically presents with symptoms such as fever, headache, and a stiff neck, but not the 'sunset sign.' Cerebral palsy (choice C) is a group of disorders affecting movement and muscle coordination, not directly related to the 'sunset sign.' Encephalitis (choice D) is inflammation of the brain, which can cause symptoms like fever, headache, and confusion, but not the specific downward eye gaze seen in the 'sunset sign.'

4. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

Correct answer: B

Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.

5. The mother of an infant diagnosed with bronchiolitis asks the nurse what causes the disease. How should the nurse respond?

Correct answer: A

Rationale: The correct answer is A: Respiratory syncytial virus (RSV). RSV is the most common cause of bronchiolitis, especially in infants. Bronchiolitis is characterized by inflammation of the small airways in the lungs. Choice B, Haemophilus influenzae, is a bacterium that can cause respiratory infections but is not the primary cause of bronchiolitis. Choice C, Parainfluenza, is a common viral infection that can cause croup and other respiratory illnesses but is not the main cause of bronchiolitis. Choice D, Rotavirus, is a virus that primarily affects the gastrointestinal system, causing diarrhea and vomiting, and is not associated with bronchiolitis.

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