the nurse is performing an otoscopic examination on a child which are normal findings the nurse should expect select all that apply

ATI RN

ATI Nursing Care of Children

1. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)

A. All below
B. A well-defined light reflex
C. A small, round, concave spot near the center of the drum
D. The tympanic membrane is a nontransparent grayish color

Correct answer: A

Rationale: A well-defined light reflex, a small concave spot, and a grayish, nontransparent tympanic membrane are normal findings during an otoscopic examination in a child.

2. Why is it difficult to assess a child’s dietary intake?

A. No systematic assessment tool has been developed
B. Biochemical analysis for assessing nutrition is expensive
C. Families usually do not understand much about nutrition
D. Recall of food consumption is frequently unreliable

Correct answer: D

Rationale: The correct answer is D. Recall of food intake, especially amounts eaten, is often unreliable. While systematic tools like the 24-hour recall and dietary history questionnaires exist, recall can still be challenging in accurately assessing a child's dietary intake. Choices A, B, and C are incorrect because systematic assessment tools do exist, biochemical analysis is not the primary method for dietary assessment, and families' understanding of nutrition may vary but is not the main reason for the difficulty in assessing a child's dietary intake.

3. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

A. Restlessness
B. Rapid capillary refill
C. Increased temperature
D. Increased blood pressure

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

4. A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?

A. Reassure the father that Visine is harmless.
B. Direct him to seek immediate medical treatment.
C. Recommend inducing vomiting with ipecac.
D. Advise him to dilute Visine by giving his daughter several glasses of water to drink.

Correct answer: B

Rationale: Visine is not harmless when ingested, and immediate medical treatment is necessary due to the risk of toxicity. Vomiting should not be induced without medical advice, and dilution with water is not an appropriate treatment.

5. Which is an accurate description of homosexual (or gay-lesbian) families?

A. A nurturing environment is lacking.
B. The children become homosexual like their parents.
C. The stability needed to raise healthy children is lacking.
D. The quality of parenting is equivalent to that of nongay parents.

Correct answer: D

Rationale: Research shows that the quality of parenting in homosexual families is equivalent to that in heterosexual families, and children thrive in nurturing environments provided by same-sex parents.