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. What reflex protects an infant from strong stimulation?
- A. Moro
- B. eye-blink
- C. sucking
- D. palmar grasp
Correct answer: B
Rationale: The correct answer is B: eye-blink. The eye-blink reflex is the one that protects an infant from strong stimulation by causing them to quickly shut their eyes in response to sudden bright light or a loud noise. This reflex helps to safeguard the infant's sensitive eyes from potential harm. The Moro reflex (choice A) is the startle reflex, the sucking reflex (choice C) helps with feeding, and the palmar grasp reflex (choice D) is when the infant's fingers close around an object placed in their hand; none of these reflexes specifically protect the infant from strong stimulation.
3. The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, "Do it later, okay?" What action should the nurse take?
- A. Postpone starting the IV until the next shift.
- B. Start the IV line and then allow for expression of feelings.
- C. Change the route of the antibiotics to PO.
- D. Postpone starting the IV line until the child is ready.
Correct answer: B
Rationale: Starting the IV as planned while allowing the child to express feelings afterward helps build trust and ensures the timely administration of necessary antibiotics. Delaying the procedure or changing the route could compromise the child's treatment.
4. Which statement is an example of reflection?
- A. I think this feeling will pass.
- B. So you are saying that life has no meaning.
- C. I'm not sure I understand what you mean.
- D. You look sad.
Correct answer: B
Rationale: The correct answer is B. Reflection involves restating the patient's words or feelings to show understanding and encourage further discussion. Choice B restates the patient's statement, demonstrating active listening and empathy.
5. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following assessments should the nurse prioritize?
- A. Assess the client's pain level.
- B. Monitor the client's respiratory rate.
- C. Measure the client's blood pressure.
- D. Check the client's bowel sounds.
Correct answer: B
Rationale: The correct answer is to monitor the client's respiratory rate. This assessment is crucial in the postoperative period to detect any respiratory complications such as hypoxia or respiratory distress. Assessing pain level (Choice A) is important but may not be the top priority as respiratory status takes precedence. Measuring blood pressure (Choice C) is also important but not as critical immediately postoperatively as monitoring respiratory function. Checking bowel sounds (Choice D) is relevant for assessing gastrointestinal function but is typically not the top priority in the immediate postoperative phase.