ATI RN
ATI Nursing Care of Children
1. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct answer: D
Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.
2. What is the first sign of puberty in girls?
- A. Acne
- B. Hair growth in the pubic area and underarms
- C. Thelarche
- D. Menarche
Correct answer: C
Rationale: The correct answer is C, Thelarche. Thelarche refers to the onset of breast development, which is typically the first sign of puberty in girls. This occurs before menarche (the first menstrual period). Choices A and B, acne and hair growth in the pubic area and underarms, are not the first signs of puberty in girls. While acne can be a common occurrence during puberty, it usually appears after other physical changes. Hair growth in the pubic area and underarms also occurs later in the puberty process.
3. How is masturbation in the pre-school child viewed?
- A. Abnormal behavior that needs to be dealt with immediately
- B. Disruptive to the family
- C. Normal behavior that can best be dealt with by ignoring and providing distraction
- D. Embarrassing to the parents
Correct answer: C
Rationale: Masturbation in preschool children is a normal behavior as they explore their bodies. It is best viewed as a natural part of development. Parents are often advised to ignore it and provide distractions rather than making the child feel ashamed or embarrassed. Choice A is incorrect because it is a natural behavior and not considered abnormal in this context. Choice B is incorrect as it does not necessarily disrupt the family. Choice D is incorrect as the focus should be on the child's development and well-being, not on the parents' feelings of embarrassment.
4. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?
- A. Place a warm moist pack on the scrotal area.
- B. Instruct the adolescent to lie down and elevate the legs.
- C. Refer the adolescent for immediate medical evaluation.
- D. Suggest that the adolescent wear a scrotum-protecting guard.
Correct answer: C
Rationale: Testicular torsion is a surgical emergency requiring immediate medical evaluation. Applying heat or elevating the legs will not alleviate the torsion, and delaying care can lead to testicular necrosis.
5. The nurse is preparing to admit a child to the hospital with a diagnosis of acute poststreptococcal glomerulonephritis. The nurse understands that the peak age at onset for this disease is what?
- A. 2 to 4 years
- B. 5 to 7 years
- C. 8 to 10 years
- D. 11 to 13 years
Correct answer: B
Rationale: The peak age for the onset of acute poststreptococcal glomerulonephritis is typically between 5 and 7 years old. This age group is most affected due to the higher incidence of streptococcal infections in school-aged children, which can lead to this renal complication.
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