the nurse is preparing a presentation on compensated decompensated and irreversible shock in children what clinical manifestations related to decompen
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

Correct answer: A

Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.

2. What is an advantage of the ventrogluteal muscle as an injection site in young children?

Correct answer: B

Rationale: The ventrogluteal site is free of significant nerves and vascular structures, making it a safer choice for intramuscular injections in young children compared to other sites that may be more prone to complications.

3. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe?

Correct answer: C

Rationale: Corrected Rationale: Currant jelly-like stools, which contain blood and mucus, are characteristic of Meckel diverticulum. This symptom occurs due to the bleeding from the ectopic gastric mucosa present in the diverticulum. Steatorrhea (choice A) is not typically associated with Meckel diverticulum. Clay-colored stools (choice B) are seen in conditions affecting the biliary system. Loose stools with undigested food (choice D) may indicate malabsorption issues, but it is not specifically linked to Meckel diverticulum.

4. At what stage can infants raise their heads and gain control of their trunks before walking due to which directional pattern of development?

Correct answer: A

Rationale: The correct answer is A: Cephalocaudal. The cephalocaudal pattern of development means that growth and motor control proceed from the head downward through the body. This explains why infants can raise their heads before they can sit and gain control of their trunks before walking. Choices B, C, and D are incorrect. Anterior to posterior refers to development from the front to the back, while proximodistal refers to development from the center of the body outward. Normal growth curve charts are used to track physical growth over time and are not directly related to the directional pattern of development in infants.

5. The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching?

Correct answer: B

Rationale: At 2 months, infants are most stimulated by visual and auditory activities, such as a music box or soft mobiles. These activities help in sensory development and are appropriate for this age.

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