ATI RN
ATI Nursing Care of Children
1. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?
- A. Recheck head control at the next visit
- B. Teach the parents appropriate exercises
- C. Schedule the child for further evaluation
- D. Refer the child for further evaluation if the anterior fontanel is still open
Correct answer: C
Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.
2. During the detoxification stage, it is a priority for the nurse to:
- A. teach skills to recognize and respond to health threatening situations
- B. increase the client’s awareness of unsatisfactory protective behaviors
- C. implement behavior modification
- D. promote homeostasis and minimize the client’s withdrawal symptoms
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
3. The influence of situational factors on moral judgments indicates that like Piaget's cognitive stages, Kohlberg's moral stages are __________.
- A. predictable and universal
- B. highly organized and sequential
- C. attained in a neat, stepwise fashion
- D. loosely organized and overlapping
Correct answer: D
Rationale: The correct answer is D. Kohlberg's moral stages are not strictly sequential but rather overlap and are more fluid, much like Piaget's cognitive stages. Choices A, B, and C are incorrect because Kohlberg's stages do not follow a neat, predictable, or highly organized pattern, as they can be revisited and experienced in varying orders.
4. A client has a new prescription for Efavirenz, an NNRTI. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime to prevent drowsiness.
- B. Take this medication with a glass of milk.
- C. Take this medication with a glass of juice.
- D. Take this medication at the same time every day.
Correct answer: A
Rationale: The correct instruction is to take Efavirenz at bedtime to prevent drowsiness and manage central nervous system side effects like dizziness and vivid dreams. While it is important to take the medication at the same time daily for consistent blood levels, the emphasis should be on bedtime to minimize the impact of these side effects. Choices B and C suggesting taking the medication with milk or juice are incorrect and not relevant to optimizing Efavirenz therapy.
5. The nurse is teaching a client about the side effects of beta blockers. What is the most important side effect to monitor?
- A. Hypotension
- B. Bradycardia
- C. Hyperkalemia
- D. Tachycardia
Correct answer: A
Rationale: The most important side effect to monitor when a client is on beta blockers is hypotension. Beta blockers can cause a significant drop in blood pressure, especially at the initiation of therapy. Monitoring for hypotension is crucial to prevent complications such as dizziness, syncope, or falls. While bradycardia can also occur with beta blockers, hypotension takes precedence due to its immediate impact on perfusion. Hyperkalemia is not a common side effect of beta blockers. Tachycardia is actually a condition that beta blockers aim to treat, so it is not a side effect to monitor.
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