ATI RN
Nursing Care of Children ATI
1. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?
- A. Avoid using any latex product.
- B. Use only non-allergenic latex products.
- C. Teach the family about long-term management of asthma.
- D. Administer medication for long-term desensitization.
Correct answer: A
Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.
2. When taking a child’s blood pressure, what percentage of the upper arm should the nurse ensure the cuff bladder width covers?
- A. 20%
- B. 40%
- C. 60%
- D. 80%
Correct answer: B
Rationale: When taking a child's blood pressure, the nurse should select a cuff with a bladder width that covers 40% of the arm circumference at the midpoint of the upper arm. This ensures accurate readings. Choosing a cuff that covers less or more than 40% can lead to incorrect blood pressure measurements. Therefore, options A, C, and D are incorrect.
3. The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for?
- A. Diarrhea
- B. Vomiting
- C. All are correct
- D. Intestinal obstruction
Correct answer: C
Rationale: Common complications of activated charcoal administration include diarrhea and vomiting. Intestinal obstruction can occur if the charcoal forms a mass in the intestines. Fluid retention is less likely and not typically a complication associated with activated charcoal.
4. According to Maslow’s hierarchy, what is the most advanced need provided by the home environment?
- A. Love
- B. Self-actualization
- C. Esteem
- D. Physiological
Correct answer: B
Rationale: The correct answer is B, self-actualization. Self-actualization is the highest level in Maslow's hierarchy of needs, representing the realization of one's full potential. While love is an essential need, self-actualization builds upon the fulfillment of basic needs like safety and love. Esteem needs relate to feelings of accomplishment and recognition, which come before self-actualization. Physiological needs such as food, water, and shelter are the most basic needs at the bottom of the hierarchy.
5. When teaching a discipline class for parents of pre-schoolers, the nurse will be guided by which principle?
- A. Using the strictest form of punishment at the time of infraction is most effective
- B. Punishment increases unwanted behavior
- C. Discipline is to teach and gradually shift control from parents to child, promoting self-discipline
- D. Discipline and punishment are the same
Correct answer: C
Rationale: The correct principle to guide the nurse when teaching a discipline class for parents of pre-schoolers is that discipline is meant to teach and gradually shift control from parents to the child, promoting self-discipline. This approach focuses on educating children on appropriate behavior rather than solely relying on punishment. Choice A is incorrect because using the strictest punishment is not the most effective method for discipline. Choice B is incorrect because punishment can reinforce unwanted behavior if not used appropriately. Choice D is incorrect because discipline and punishment are not synonymous; discipline involves a broader aspect of teaching and guiding behavior.
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