the nurse is performing an oral examination on a preschool child which strategies should the nurse use to encourage the child to open the mouth for th
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

Correct answer: D

Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.

2. Which congenital heart defect causes a "boot-shaped" heart on a chest x-ray?

Correct answer: A

Rationale: The correct answer is A: Tetralogy of Fallot. Tetralogy of Fallot, a congenital heart defect with four distinct abnormalities, often presents with a "boot-shaped" heart on chest x-ray due to right ventricular hypertrophy. This characteristic finding is due to the specific combination of defects in this condition. Coarctation of the aorta (choice B), Transposition of the great arteries (choice C), and Ventricular septal defect (choice D) do not typically result in a "boot-shaped" heart on a chest x-ray like Tetralogy of Fallot does.

3. An infant requires surgery for repair of a cleft lip. An important priority of the preoperative nursing care is which?

Correct answer: B

Rationale: Performing a baseline physical and behavioral assessment is crucial to determine the infant's current health status and to identify any potential risks before surgery.

4. What should the nurse include in the discharge instructions for the parents of an infant diagnosed with acute otitis media?

Correct answer: D

Rationale: Acetaminophen (Tylenol) is recommended to help relieve the discomfort associated with acute otitis media, such as pain and fever. Elevating the baby's head during sleep can also help with drainage and relieve pressure, making choice A incorrect. Administering an antibiotic may be necessary for bacterial otitis media but is not usually the first-line treatment for acute otitis media, so choice B is incorrect. Placing the baby to sleep with a bottle can increase the risk of ear infections due to the pooling of milk around the Eustachian tube, so choice C is incorrect.

5. Which nursing action is developmentally appropriate when caring for a hospitalized school-age child?

Correct answer: C

Rationale: Offering medical equipment to play with prior to a procedure is developmentally appropriate when caring for a hospitalized school-age child. Allowing the child to familiarize themselves with the equipment helps reduce fear and anxiety about the upcoming procedure. Choices A, B, and D are not as appropriate for a school-age child. Providing brochures regarding sexuality is not developmentally appropriate for this age group. Giving clear instructions about treatment details may overwhelm a child of this age. Using toys for distraction during a painful procedure is more suitable for younger children.

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