ATI RN
Nursing Care of Children Final ATI
1. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?
- A. Respiratory rate of 20 breaths per minute
- B. Heart rate of 89 beats per minute
- C. Heart rate of 120 beats per minute
- D. Respiratory rate of 24 breaths per minute
Correct answer: C
Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.
2. A client with heart failure is prescribed furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include during discharge teaching?
- A. Monitor for increased blood pressure
- B. Increase intake of high-potassium foods
- C. Expect an increase in swelling in the hands and feet
- D. Take the second dose at bedtime
Correct answer: B
Rationale: The correct answer is to instruct the client to increase their intake of high-potassium foods. Furosemide can lead to hypokalemia, a condition of low potassium levels in the blood. Increasing the consumption of high-potassium foods helps prevent this adverse effect. Monitoring for increased blood pressure (choice A) is not directly related to furosemide use. Expecting an increase in swelling (choice C) is incorrect as furosemide is a diuretic that helps reduce swelling. Taking the second dose at bedtime (choice D) is not necessary unless prescribed by the healthcare provider.
3. Why is it important to assess for in a child receiving prednisone to treat nephrotic syndrome?
- A. Infection
- B. Urinary retention
- C. Easy bruising
- D. Hypoglycemia
Correct answer: A
Rationale: When a child is receiving prednisone to treat nephrotic syndrome, it is crucial to assess for infection. Prednisone suppresses the immune system, making the child more vulnerable to infections. Since steroids can mask typical signs of infection, it is essential to look for subtle symptoms to ensure prompt treatment and prevent complications. Therefore, choices B, C, and D are incorrect as they are not directly related to the impact of prednisone therapy in nephrotic syndrome.
4. When is infertility said to exist?
- A. When a woman has no uterus
- B. When a woman has no children
- C. When a couple has been trying to conceive for 1 year without success
- D. When a couple has desired a child for 6 months
Correct answer: C: When a couple has been trying to conceive for 1 year without success
Rationale: Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most couples. Therefore, the correct answer is C. A, B, and D are incorrect. While having no uterus (choice A) may result in infertility, it is not the sole determining factor. Similarly, not having children (choice B) does not automatically indicate infertility. Lastly, the time frame of 6 months (choice D) is not sufficient to determine infertility; typically, a year of trying without success is required for such a diagnosis.
5. Franklin wakes up in a homeless shelter in another town. He doesn't know where he is or how he got there, and he's confused when people say he has been calling himself Anthony. This is most likely an episode of dissociative?
- A. Amnesia
- B. Dissociative fugue
- C. Wandering
- D. Flight of ideas
Correct answer: B
Rationale: The correct answer is B, Dissociative fugue. In the scenario described, Franklin experiencing memory loss, travel to another town, assuming a new identity (calling himself Anthony) aligns with dissociative fugue. Amnesia (Choice A) involves memory loss without the additional aspects of travel and assuming a new identity. Wandering (Choice C) is vague and does not encompass the complete set of symptoms described. Flight of ideas (Choice D) is a symptom of conditions like mania, not dissociative disorders.