the nurse is preparing to complete documentation on a patients chart which should be included in documentation of nursing care select all that apply
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

2. The nurse is preparing to admit a 6-month-old child with gastroesophageal reflux disease. What clinical manifestations should the nurse expect to observe?

Correct answer: D

Rationale: The correct answer is D, as gastroesophageal reflux disease (GERD) in infants typically presents with symptoms such as spitting up, failure to thrive, excessive crying, and respiratory problems due to aspiration. Bilious vomiting is not a common symptom of GERD in infants and may indicate a different or more severe condition, such as intestinal obstruction or other gastrointestinal issues. Therefore, choices A, B, and C are all expected clinical manifestations of GERD in a 6-month-old child, making option D the correct answer.

3. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis?

Correct answer: B

Rationale: Postinfectious glomerulonephritis is typically caused by immune complex deposition in the glomeruli following a streptococcal infection. This immune response leads to inflammation and impaired kidney function.

4. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

Correct answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

5. What organism is a parasite that causes acute diarrhea?

Correct answer: C

Rationale: Giardia lamblia is a protozoan parasite known to cause acute diarrhea, often through contaminated water or food. Shigella, Salmonella, and E. coli are bacterial pathogens that also cause diarrhea but are not parasites.

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