ATI RN
ATI Nursing Care of Children
1. An infant is born with anencephaly. Based on the knowledge of this diagnosis, what information does the nurse consider when interacting with the family?
- A. Many treatment options exist.
- B. Immediate surgery is necessary.
- C. The condition is incompatible with life.
- D. The child will have permanent disabilities.
Correct answer: C
Rationale: The correct answer is C: 'The condition is incompatible with life.' Anencephaly is the most serious neural tube defect where both hemispheres of the brain are absent. It is incompatible with life, as there are no medical or surgical treatment options available. While some infants with mature brain stem function can maintain vital functions for a short period, anencephaly is ultimately not survivable. Choice A is incorrect as there are no treatment options for anencephaly. Choice B is incorrect as immediate surgery is not necessary for this condition. Choice D is incorrect as an infant with anencephaly will not have permanent disabilities since the condition is not compatible with life.
2. During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct answer: A
Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.
3. When administering azoles in the home setting, the home health nurse should prioritize educational interventions that address what nursing diagnosis?
- A. Risk for injury related to antifungal therapy
- B. Risk for acute confusion related to antifungal therapy
- C. Risk for infection related to antifungal therapy
- D. Risk for falls related to antifungal therapy
Correct answer: A
Rationale: The correct answer is A: Risk for injury related to antifungal therapy. When administering azoles, the priority is to educate patients and caregivers about potential side effects that could lead to injury, such as hepatotoxicity or allergic reactions. Choices B, C, and D are incorrect because acute confusion, infection, and falls are not typically associated with azole therapy.
4. When measuring the leg circumference of a client with bipedal edema, what position is best to ensure accurate measurements?
- A. Dorsal recumbent
- B. Sitting
- C. Standing
- D. Supine
Correct answer: A
Rationale: When measuring the leg circumference of a client with bipedal edema, the best position to ensure accurate and consistent measurements is the dorsal recumbent position. This position allows the legs to be positioned comfortably, and the individual is lying on their back with legs extended, facilitating accurate measurement of the circumference without the influence of gravity. Sitting, standing, and supine positions may not provide optimal conditions for accurate leg circumference measurements, particularly in clients with bipedal edema where positioning and consistency are crucial. Sitting and standing positions may not allow for consistent leg positioning and could introduce errors due to the effects of gravity on the fluid distribution. The supine position, while similar to dorsal recumbent, may not be as comfortable for the client and could still be influenced by gravity when measuring leg circumference.
5. Which of the following is a challenge the profession of nursing faced?
- A. Nursing contributing to the stigma of AIDS in the 1980s out of fear.
- B. Nursing practice flourishing in field hospitals during the Korean War with abundant supplies and equipment.
- C. Many nurses feeling frustrated with the lack of independent functioning after the Vietnam War.
- D. A decline in the number of hospice nurses due to ethical dilemmas.
Correct answer: C
Rationale: The correct answer is C. After the Vietnam War, many nurses felt frustrated with the lack of independent functioning when they returned home. This challenge was faced by the profession of nursing as nurses who functioned independently in mobile hospital units during the war found themselves restricted in their practice upon returning. Choices A, B, and D are incorrect because they do not address the specific challenge of lack of independent functioning faced by nurses after the Vietnam War.