ATI RN
Nursing Care of Children ATI
1. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs as do their other children. The nurse’s reply should be based on what?
- A. The child is too young to digest hot dogs.
- B. The child is too young to eat hot dogs safely.
- C. Hot dogs must be sliced into sections to prevent aspiration.
- D. Hot dogs must be cut into small, irregular pieces to prevent aspiration.
Correct answer: D
Rationale: Cutting hot dogs into small, irregular pieces reduces the risk of aspiration, which is a significant choking hazard for young children.
2. What is the priority nursing diagnosis for a client with immobility?
- A. Constipation related to immobility
- B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
- D. Risk for disuse syndrome as evidenced by immobility
Correct answer: C
Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.
3. Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?
- A. Hepatotoxicity
- B. Wernicke's aphasia
- C. Suicidal ideations
- D. Diarrhea
Correct answer: A
Rationale: The correct answer is A: Hepatotoxicity. Disulfiram is known to cause hepatotoxicity as a severe adverse effect. This occurs due to the inhibition of aldehyde dehydrogenase, leading to the accumulation of acetaldehyde when alcohol is consumed. Wernicke's aphasia (Choice B) is a language disorder unrelated to disulfiram therapy. Suicidal ideations (Choice C) may be associated with certain medications, but it is not a common adverse effect of disulfiram. Diarrhea (Choice D) is not a typical adverse effect of disulfiram.
4. A nurse is caring for a client who is postoperative following a thyroidectomy. The nurse should identify that which of the following client reports is an indication of hypocalcemia?
- A. Constipation
- B. Frequent urination
- C. Numbness and tingling of the fingers
- D. Increased thirst
Correct answer: C
Rationale: The correct answer is C: 'Numbness and tingling of the fingers.' Post-thyroidectomy, hypocalcemia is a concern due to potential damage to the parathyroid glands that regulate calcium levels. Numbness and tingling of the fingers are classic signs of hypocalcemia. Constipation (Choice A) is not typically associated with hypocalcemia. Frequent urination (Choice B) is more indicative of conditions like diabetes or a urinary tract infection. Increased thirst (Choice D) is commonly seen in conditions such as diabetes insipidus or uncontrolled diabetes mellitus, not specifically related to hypocalcemia.
5. A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?
- A. Provide chicken with cream sauce.
- B. Avoid serving fish with fins and scales.
- C. Provide unleavened bread.
- D. Avoid serving foods containing lamb.
Correct answer: C
Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include avoiding leavened bread. Providing unleavened bread aligns with these restrictions and ensures the client's observance of the holiday. Choices A, B, and D are incorrect because serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not specific dietary requirements related to observing Passover in Orthodox Judaism.
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