during a funduscopic examination of a school age child the nurse notes a brilliant uniform red reflex in both eyes the nurse should recognize that thi
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?

Correct answer: A

Rationale: A brilliant, uniform red reflex in both eyes is a normal finding, indicating that the retina is healthy and there are no significant obstructions in the visual pathway.

2. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?

Correct answer: B

Rationale: Frequent monitoring of the IV site for signs of infiltration is crucial to prevent tissue damage, especially in pediatric patients. Changing the site every 24 hours is unnecessary unless complications arise, and using a macrodropper is not specific to pediatric care.

3. The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.)

Correct answer: D

Rationale: High fever, especially in very young infants, or the presence of a stiff neck can indicate a serious infection requiring immediate attention. A fever lasting more than 3 days also warrants medical evaluation.

4. What illnesses does respiratory hygiene and cough etiquette by the Centers for Disease Control and Prevention (CDC) prevent?

Correct answer: C

Rationale: The correct answer is C: RSV, influenza, and adenovirus. The CDC recommends respiratory hygiene and etiquette to prevent the transmission of respiratory syncytial virus (RSV), influenza, adenovirus, and other droplet-transmitted unknown viruses. Choices A, B, and D are incorrect because HBV, Hib, pertussis, HSV, and varicella are not typically transmitted via droplets but through other modes of transmission.

5. Prior to giving a hospitalized pre-schooler an injection, the nurse gives the child’s teddy bear a “shot” first. This method is known as:

Correct answer: D

Rationale: The correct answer is D: Dramatic play. Dramatic play involves children acting out experiences to better understand them and reduce fear. In this scenario, by giving the teddy bear a 'shot' first, the nurse is engaging in dramatic play to help the child comprehend and feel more comfortable with the upcoming injection.\n A: Critical play involves critical thinking and problem-solving, not acting out scenarios.\n B: Role play typically involves pretending to be someone else, not necessarily acting out a specific experience.\n C: Diversionary activity aims to distract or redirect attention, which is different from the purpose of dramatic play in this context.

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