the nurse is assessing a 3 year old child which assessment finding would the nurse identify as abnormal
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Nursing Elites

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?

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. What organism is a parasite that causes acute diarrhea?

Correct answer: C

Rationale: Giardia lamblia is a protozoan parasite known to cause acute diarrhea, often through contaminated water or food. Shigella, Salmonella, and E. coli are bacterial pathogens that also cause diarrhea but are not parasites.

3. The parent of a 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurse's best response?

Correct answer: C

Rationale: Breastfed infants may need fluoride supplements starting at 6 months if they are not receiving fluoride from other sources, such as drinking water.

4. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?

Correct answer: B

Rationale: Hypotonic dehydration occurs when the loss of electrolytes exceeds the loss of water, leading to a decrease in plasma osmolarity. This often occurs when sodium loss is greater than water loss, as in diarrhea or vomiting.

5. An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions?

Correct answer: B

Rationale: Supporting an adolescent in making decisions about their care reflects the moral value of autonomy, emphasizing the importance of respecting the patient's right to make informed choices.

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