ATI RN
ATI Nursing Care of Children 2019 B
1. The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula?
- A. Jitteriness
- B. Meconium ileus
- C. Excessive frothy saliva
- D. Increased need for sleep
Correct answer: C
Rationale: Excessive frothy saliva is a hallmark sign of tracheoesophageal fistula. The abnormal connection between the esophagus and trachea causes difficulty in swallowing, leading to an accumulation of saliva in the mouth. This symptom is crucial for early identification and management of tracheoesophageal fistula. Choices A, B, and D are incorrect as they are not specific indicators of tracheoesophageal fistula.
2. What term describes the invagination of one segment of bowel within another?
- A. Atresia
- B. Stenosis
- C. Herniation
- D. Intussusception
Correct answer: D
Rationale: Intussusception is the correct answer. It refers to the condition where one segment of the bowel folds into another, leading to an obstruction. Atresia (Choice A) is the absence or abnormal closure of a normal opening or tubular structure. Stenosis (Choice B) is the narrowing of a passage in the body. Herniation (Choice C) is the abnormal protrusion of an organ or tissue through a defect in its surrounding walls. Intussusception is a medical emergency commonly observed in infants and young children and necessitates prompt intervention to prevent severe complications.
3. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?
- A. Suggestive of chronic pulmonary disease
- B. Suggestive of impending respiratory failure
- C. An abnormal finding warranting investigation
- D. A normal finding in infants younger than 1 year of age
Correct answer: C
Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.
4. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?
- A. The parent is trying to feed the child only what the child likes most
- B. Hispanics believe the evil eye enters when a person gets cold
- C. The parent is trying to restore normal balance through appropriate hot remedies
- D. Hispanics believe an innate energy called chi is strengthened by eating soup
Correct answer: C
Rationale: In Hispanic culture, the balance between hot and cold is important, and the parent may be giving the child broth to restore this balance while avoiding "cold" foods.
5. A school-age client is in the playroom when the respiratory therapist arrives to give a scheduled breathing treatment. What is the most appropriate nursing action?
- A. Escort the child to their room and ask the child-life specialist to bring toys to the bedside
- B. Reschedule the treatment for a later time
- C. Assist the child back to their room for the treatment but reassure them that they may return when the procedure is completed
- D. Show the respiratory therapist to the playroom
Correct answer: C
Rationale: The most appropriate action is to assist the child back to their room for the treatment but reassure them that they may return when the procedure is completed. This approach ensures that the child receives the necessary treatment while also acknowledging their desire to continue playing in the playroom. Choice A is incorrect because it suggests moving the child to the room and asking the child-life specialist to bring toys, which may not be necessary. Choice B is incorrect as rescheduling the treatment may not be in the best interest of the child's health. Choice D is incorrect as the nurse should guide the child back to their room for the treatment.
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