ATI RN
Nursing Care of Children ATI
1. The clinic nurse is assessing a child with a heavy ascariasis lumbricoides (common roundworm) infection. Which assessment findings should the nurse expect?
- A. Anemia
- B. Anorexia
- C. All are applicable
- D. Intestinal colic
Correct answer: D
Rationale: A heavy roundworm infection can cause anemia, anorexia, irritability, and an enlarged abdomen due to the worms’ effects on nutrient absorption and intestinal function.
2. A client with a body mass index of 28 is seeking dietary advice. Which of the following actions should the nurse take?
- A. Encourage the client to continue their current daily caloric intake.
- B. Recommend a total fiber intake of 12g per day.
- C. Advise the client to add 500 calories per day to their diet.
- D. Refer the client to a weight-loss support group.
Correct answer: D
Rationale: Referring the client to a weight-loss support group is the most appropriate action for a client with a body mass index of 28. This action can provide the necessary support, guidance, and motivation to help the client achieve their weight loss goals. Encouraging the client to continue their current daily caloric intake (Choice A) may not address the need for weight loss. Recommending a total fiber intake of 12g per day (Choice B) is important for overall health but may not directly address weight loss. Advising the client to add 500 calories per day to their diet (Choice C) would not be beneficial for weight loss in this scenario.
3. A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?
- A. Lipsmacking
- B. Agranulocytosis
- C. Clang association
- D. Alopecia
Correct answer: A
Rationale: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.
4. Which of the following statements is true regarding nursing ethics?
- A. Nursing ethics focus on the organizational level at the workplace.
- B. Nursing ethics focus on the duties and rules of behavior for professional nurses.
- C. Nursing ethics focus on the moral character of nurses.
- D. Nursing ethics focus on the experiences and needs of nurses.
Correct answer: B
Rationale: The correct answer is B: 'Nursing ethics focus on the duties and rules of behavior for professional nurses.' Nursing ethics primarily revolve around the principles and standards that guide the actions and decisions of nurses in their professional roles. Choice A is incorrect as nursing ethics are not limited to the organizational level but extend to individual conduct. Choice C is incorrect as while moral character is important, nursing ethics encompass more than just character traits. Choice D is incorrect as nursing ethics are centered on professional responsibilities rather than personal experiences and needs.
5. What are the expected symptoms of a thrombotic stroke?
- A. Gradual loss of function on one side of the body
- B. Sudden loss of consciousness
- C. Severe headache and confusion
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' In a thrombotic stroke, a clot blocks a cerebral artery, leading to a gradual onset of symptoms such as weakness, numbness, or paralysis on one side of the body. Choice B, 'Sudden loss of consciousness,' is more characteristic of a hemorrhagic stroke. Choice C, 'Severe headache and confusion,' are often associated with subarachnoid hemorrhage rather than thrombotic stroke. Choice D, 'Loss of sensation in the affected limb,' is not a typical symptom pattern for a thrombotic stroke, which usually presents with motor deficits.
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