ATI RN
RN Nursing Care of Children 2019 With NGN
1. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?
- A. Not useful as the only indicator for pain
- B. Best indicator of pain in children of all ages
- C. Most valuable when children also report having pain
- D. Essential to determine whether a child is telling the truth about pain
Correct answer: A
Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.
2. In assessing sexual maturity levels, which tool would you expect to use?
- A. Denver II Developmental Screening
- B. Tanner staging
- C. Antibody testing
- D. Nursing process
Correct answer: B
Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.
3. Which laboratory test would be most important for the nurse to assess when caring for a toddler suspected of having cystic fibrosis?
- A. Liver enzymes
- B. Serum calcium
- C. Sweat chloride test
- D. Urine creatinine
Correct answer: C
Rationale: The sweat chloride test is the primary diagnostic test for cystic fibrosis. Cystic fibrosis is characterized by abnormal transport of chloride and sodium across epithelial cell membranes, leading to increased chloride in sweat. This test is crucial for diagnosing cystic fibrosis in suspected cases. Liver enzymes (Choice A), serum calcium (Choice B), and urine creatinine (Choice D) are not specific tests for cystic fibrosis and would not provide the necessary information for diagnosis in this case.
4. What do mortality statistics describe?
- A. Disease occurring regularly within a geographic location
- B. The number of individuals who have died over a specific period
- C. The prevalence of specific illness in the population at a particular time
- D. Disease occurring in more than the number of expected cases in a community
Correct answer: B
Rationale: Mortality statistics describe the number of individuals who have died over a specific period, providing insight into public health concerns.
5. The clinic nurse is assessing a child with a heavy ascariasis lumbricoides (common roundworm) infection. Which assessment findings should the nurse expect?
- A. Anemia
- B. Anorexia
- C. All are applicable
- D. Intestinal colic
Correct answer: D
Rationale: A heavy roundworm infection can cause anemia, anorexia, irritability, and an enlarged abdomen due to the worms’ effects on nutrient absorption and intestinal function.
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