ATI RN
Nursing Care of Children Final ATI
1. An adolescent states, “I want to be a doctor or a lawyer when I grow up because I like taking care of people.” Which Eriksonian challenge is the adolescent attempting?
- A. Identity vs. role diffusion
- B. Trust vs. mistrust
- C. Industry vs. inferiority
- D. Autonomy vs. shame and doubt
Correct answer: A
Rationale: The correct answer is A: Identity vs. role diffusion. During adolescence, individuals face the challenge of forming a cohesive sense of self and identity. In this scenario, the adolescent's desire to become a doctor or lawyer reflects the exploration of potential roles and career paths, indicating an attempt to establish a clear identity. Choices B, C, and D are incorrect. Trust vs. mistrust is a challenge experienced in infancy, industry vs. inferiority is relevant to the school-age period, and autonomy vs. shame and doubt is associated with the toddler stage, not adolescence.
2. The parent of a 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurse's best response?
- A. The infant needs to begin taking them now.
- B. Supplements are not needed if you drink fluoridated water.
- C. The infant may need to begin taking them at age 6 months.
- D. The infant can have infant cereal mixed with fluoridated water instead of supplements.
Correct answer: C
Rationale: Breastfed infants may need fluoride supplements starting at 6 months if they are not receiving fluoride from other sources, such as drinking water.
3. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?
- A. Retake the temperature in 15 minutes after giving the Tylenol.
- B. Place a warm blanket on the child so chilling does not occur.
- C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
- D. Use cold compresses instead of Tylenol to control the fever.
Correct answer: C
Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.
4. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include?
- A. Dilating the stoma
- B. Assessing bowel function
- C. Limitation of physical activities
- D. Measures to prevent prolapse of the rectum
Correct answer: B
Rationale: Postoperative teaching should focus on assessing bowel function to ensure the colostomy is functioning properly. This includes monitoring stool output, color, consistency, and signs of infection or blockage. Choice A, dilating the stoma, is not recommended without healthcare provider guidance, as it can lead to complications. Choice C, limitation of physical activities, may not be as crucial immediately after colostomy creation. Choice D, measures to prevent prolapse of the rectum, is more relevant for conditions like rectal prolapse and not specifically for a colostomy.
5. What is the most effective method to prevent infection in the newborn?
- A. Using disposable items
- B. Practicing proper hand hygiene by staff and family
- C. Administering prophylactic antibiotics
- D. Isolating the newborn from others
Correct answer: B
Rationale: The most effective method to prevent infection in newborns is by practicing proper hand hygiene by staff and family. This is crucial as it helps reduce the transmission of infectious agents, protecting vulnerable newborns. Using disposable items may help, but proper hand hygiene is more effective. Administering prophylactic antibiotics without a specific indication can lead to antibiotic resistance and is not recommended. Isolating the newborn from others is not practical and may not be necessary if proper hand hygiene is maintained.
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