the mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning the nurse suspects foreign b
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. The mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic occurrence is most likely responsible for the presenting signs?

Correct answer: C

Rationale: The symptoms of gagging and drooling suggest that the foreign object is likely lodged in the esophagus. This can cause significant discomfort and potential complications, requiring immediate medical evaluation.

2. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose test.” What is the purpose of this test?

Correct answer: B

Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.

3. The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia?

Correct answer: B

Rationale: Physiologic anemia is caused by the transition from fetal to adult hemoglobin, with fetal hemoglobin having a shorter lifespan, leading to a temporary decrease in red blood cells.

4. When checking the intravenous (IV) site on a child, the nurse should take which action?

Correct answer: C

Rationale: Looking at and palpating the IV site helps assess for signs of infiltration or infection, such as swelling, redness, or pain. Simply looking or asking the child may miss subtle signs, and removing all the tape unnecessarily disrupts the site.

5. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?

Correct answer: D

Rationale: A vesicle is an elevated, circumscribed lesion filled with serous fluid, typically less than 1 cm in diameter.

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