ATI RN
Nursing Care of Children Final ATI
1. The nurse is assessing a child with type 2 diabetes. The child is awake and alert with a serum glucose of 60 mg/dL. What action should the nurse take?
- A. Administer Insulin.
- B. Administer Epinephrine.
- C. Give 15 grams of carbohydrates.
- D. Give glucagon by injection.
Correct answer: C
Rationale: For a conscious child with mild hypoglycemia, giving 15 grams of fast-acting carbohydrates is the appropriate intervention. This can quickly raise blood glucose levels to prevent further complications. Administering insulin (Choice A) would further lower the glucose level, which is not suitable in this scenario. Administering epinephrine (Choice B) is not indicated for hypoglycemia. Glucagon (Choice D) is used for severe hypoglycemia with altered consciousness, not for mild cases where the child is awake and alert.
2. A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?
- A. Restate what the physician has told her about plastic surgery
- B. Suggest holding her baby without making eye contact
- C. Encourage and allow the mother to express her feelings
- D. Recognize and allow the mother to express her feelings
Correct answer: D
Rationale: In this situation, the priority is to acknowledge and validate the mother's feelings, creating a supportive environment for her. Option D is correct as it focuses on recognizing and allowing the mother to express her emotions. This approach can help build trust and facilitate communication. Options A and B are incorrect as they do not address the mother's emotional needs and may come across as dismissive. Option C is less appropriate as it only encourages expression without explicitly recognizing the mother's current emotional state.
3. A 4-month-old infant is discharged home after surgery for the repair of a cleft lip. What should instructions to the parents include?
- A. Provide crib toys for distraction
- B. Breast- or bottle-feeding can begin immediately
- C. Give pain medication to the infant to minimize crying
- D. Leave the infant in the crib at all times to prevent suture strain
Correct answer: C
Rationale: Pain management is essential postoperatively to reduce crying, which could place strain on the surgical site. Feeding and holding the infant are allowed, but care should be taken to avoid placing pressure on the suture line.
4. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
- A. Cyst
- B. Papule
- C. Pustule
- D. Vesicle
Correct answer: D
Rationale: A vesicle is an elevated, circumscribed lesion filled with serous fluid, typically less than 1 cm in diameter.
5. According to Maslow’s hierarchy, what is the most advanced need provided by the home environment?
- A. Love
- B. Self-actualization
- C. Esteem
- D. Physiological
Correct answer: B
Rationale: The correct answer is B, self-actualization. Self-actualization is the highest level in Maslow's hierarchy of needs, representing the realization of one's full potential. While love is an essential need, self-actualization builds upon the fulfillment of basic needs like safety and love. Esteem needs relate to feelings of accomplishment and recognition, which come before self-actualization. Physiological needs such as food, water, and shelter are the most basic needs at the bottom of the hierarchy.
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