what clinical manifestations should the nurse expect to see as shock progresses in a child and becomes decompensated shock
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

2. A 4-month-old infant is discharged home after surgery for the repair of a cleft lip. What should instructions to the parents include?

Correct answer: C

Rationale: Pain management is essential postoperatively to reduce crying, which could place strain on the surgical site. Feeding and holding the infant are allowed, but care should be taken to avoid placing pressure on the suture line.

3. In assessing sexual maturity levels, which tool would you expect to use?

Correct answer: B

Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.

4. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child?

Correct answer: B

Rationale: Preparation is essential even for a young child, as they need to adjust to the temporary colostomy and understand the changes to their body, which can be confusing and distressing without proper explanation.

5. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

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.

Similar Questions

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A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?
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