ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure?
- A. "We will give you your shot when your mommy comes back."
- B. "I will wipe your skin with a magic wipe and then hold the needle like this and say one, two, three, go and give you your shot. Are you ready?"
- C. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker."
- D. "This is a magic sword that will give you your medicine and make you all better."
Correct answer: C
Rationale: The correct answer is C because it acknowledges the child's feelings, provides clear instructions, and offers comfort and rewards to help the child cope with the procedure. Choice A is not appropriate as it may create anxiety about the injection. Choice B uses the term 'magic,' which may confuse the child and lead to fear. Choice D introduces a fantasy element that may not be beneficial in preparing the child for the injection.
2. In children with Type 1 diabetes, what is a common early sign of hypoglycemia?
- A. Irritability
- B. Rapid heartbeat
- C. Confusion
- D. Sweating
Correct answer: D
Rationale: Sweating is indeed one of the earliest signs of hypoglycemia in children with Type 1 diabetes. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, which can lead to sweating. While irritability, rapid heartbeat, and confusion can also be seen in hypoglycemia, sweating is particularly common as a quick indicator of low blood sugar levels in children with Type 1 diabetes.
3. The nurse suspects that a child has ingested some type of poison. What clinical manifestation would be most suggestive that the poison was a corrosive product?
- A. Tinnitus
- B. Disorientation
- C. Stupor, lethargy, and coma
- D. Edema of the lips, tongue, and pharynx
Correct answer: D
Rationale: Edema of the lips, tongue, and pharynx is a characteristic sign of corrosive poisoning, indicating damage to mucous membranes from ingestion of a caustic substance. Other symptoms may vary depending on the poison but are not as specific to corrosive ingestion.
4. What is the priority nursing intervention for a child with epiglottitis?
- A. Administer antibiotics
- B. Maintain airway patency
- C. Provide hydration
- D. Monitor vital signs
Correct answer: B
Rationale: The correct answer is B: Maintain airway patency. When dealing with a child with epiglottitis, the priority nursing intervention is to ensure airway patency to prevent airway obstruction, which can lead to respiratory distress or failure. Administering antibiotics (choice A) is important to treat the infection, but airway management takes precedence. Providing hydration (choice C) and monitoring vital signs (choice D) are essential aspects of care but are secondary to securing the airway in a child with epiglottitis.
5. 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.)
- A. Lightly brush the palate with a cotton swab
- B. Perform the examination in front of a mirror
- C. Let the child examine someone else's mouth first
- D. All of the above
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.