ATI RN
ATI Nursing Care of Children
1. The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?
- A. Pedals tricycle without assistance
- B. Unscrews a bolt on a toy
- C. Falls when bending over to touch toes
- D. Builds a tower of 10 cubes
Correct answer: C
Rationale: The correct answer is C. Falling when bending over to touch toes could indicate a developmental delay or a balance issue that may need further assessment. Choices A, B, and D are typical developmental milestones for a 3-year-old child. Pedaling a tricycle without assistance, unscrewing a bolt on a toy, and building a tower of 10 cubes are all age-appropriate activities for a child of this age.
2. Depression __________.
- A. declines with age
- B. responds to treatment that is completely covered by Medicare
- C. is rarely related to physical illness or pain
- D. can lead to cognitive deterioration
Correct answer: D
Rationale: The correct answer is D: 'can lead to cognitive deterioration.' Depression, particularly in older adults, can significantly impair cognitive function, leading to further mental health challenges. Choices A, B, and C are incorrect. Depression does not necessarily decline with age, treatment coverage may vary, and depression can indeed be related to physical illness or pain.
3. The nurse is caring for a client on amiodarone who complains of visual disturbances. What is the nurse’s best response?
- A. Notify the healthcare provider immediately.
- B. Reassure the client that this is a common side effect.
- C. Advise the client to monitor their symptoms at home.
- D. Suggest the client reduce physical activity.
Correct answer: A
Rationale: The correct answer is to notify the healthcare provider immediately. Visual disturbances in a client taking amiodarone can indicate amiodarone toxicity, a serious side effect. Notifying the healthcare provider promptly is essential for further assessment and management. Reassuring the client that this is a common side effect (choice B) is incorrect as visual disturbances should not be dismissed without evaluation. Advising the client to monitor their symptoms at home (choice C) may delay necessary intervention. Suggesting the client reduce physical activity (choice D) is unrelated to addressing visual disturbances caused by amiodarone.
4. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Urine output of 20 ml/hr
- B. Montevideo units consistently at 300 mm Hg
- C. FHR pattern with absent variability
- D. Contractions every 5 minutes that last 30 seconds
Correct answer: D
Rationale: The correct answer is D because contractions every 5 minutes that last 30 seconds indicate that the rate of infusion should be increased. This pattern suggests weak contractions or intervals that are too far apart, requiring an adjustment to improve labor progress. Option A is incorrect as a low urine output is not directly related to the need for an increase in the oxytocin infusion rate. Option B, Montevideo units consistently at 300 mm Hg, is incorrect because it is a measure of intrauterine pressure and does not determine the need for an increase in oxytocin infusion. Option C, FHR pattern with absent variability, is incorrect as it may indicate fetal distress but does not specifically relate to the need for adjusting the oxytocin infusion rate.
5. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)
- A. A client on birth control pills
- B. A client who is immobile
- C. A client on an anticoagulant
- D. A client with dementia who has been wandering
Correct answer: a
Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.