ATI RN
Nursing Care of Children ATI
1. The clinic nurse is instructing parents about caring for a toddler with ascariasis (common roundworm). Which statement made by the parents indicates a need for further teaching?
- A. We will wash our hands often, especially after diaper changes
- B. We know that roundworm can be transmitted from person to person
- C. We will be sure to continue the nitazoxanide (Alinia) orally for 3 days
- D. We will bring a stool sample to the clinic for examination in 2 weeks
Correct answer: B
Rationale: Roundworm (ascariasis) is typically transmitted through ingestion of contaminated soil, not directly from person to person. This statement indicates a misunderstanding requiring clarification.
2. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?
- A. Not useful as the only indicator for pain
- B. Best indicator of pain in children of all ages
- C. Most valuable when children also report having pain
- D. Essential to determine whether a child is telling the truth about pain
Correct answer: A
Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.
3. A parent brings their 4-year-old child for a check-up. Which finding would concern the nurse?
- A. Ectomorphic body type
- B. Resting pulse rate of 120
- C. Weight gain of 5 lb (2.27 kg) in the past year
- D. No increase in appetite compared with that in toddler years
Correct answer: B
Rationale: A resting pulse rate of 120 is elevated for a 4-year-old and may indicate an underlying issue that needs further investigation. An ectomorphic body type is a body shape and not typically a cause for concern. Weight gain within normal limits and no significant change in appetite are generally positive findings in a growing child.
4. A new mom is instructed to have her toddler brush his teeth every night after dinner. This is an example of __________ which increases the toddler’s sense of security and self-mastery.
- A. Negativism
- B. Diversionary activity
- C. Critical play
- D. Ritualism
Correct answer: D
Rationale: The correct answer is D, Ritualism. Establishing routines like brushing teeth every night after dinner helps toddlers feel secure and in control. Choice A, Negativism, refers to a child's oppositional behavior. Choice B, Diversionary activity, involves redirecting attention to something else. Choice C, Critical play, does not relate to the scenario of establishing a routine for the toddler.
5. What is the recommended method to assess hydration status in infants?
- A. Capillary refill time
- B. Skin turgor
- C. Urine output
- D. Mucous membranes
Correct answer: C
Rationale: The correct answer is C: Urine output. Assessing urine output is a recommended method to determine hydration status in infants. Adequate urine output indicates good hydration, while decreased urine output may suggest dehydration. Capillary refill time (Choice A) is more indicative of circulatory status rather than hydration. Skin turgor (Choice B) is a useful assessment in adults but can be less reliable in infants. Checking mucous membranes (Choice D) can provide some information on hydration, but it is not as reliable as assessing urine output in infants.
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