ATI RN
ATI Nursing Care of Children 2019 B
1. What is a common sign of moderate dehydration in children?
- A. Dry mucous membranes
- B. Normal capillary refill
- C. Hyperactive bowel sounds
- D. Edema
Correct answer: A
Rationale: Dry mucous membranes are a common sign of moderate dehydration in children, indicating a loss of bodily fluids. When a child is moderately dehydrated, the mucous membranes in the mouth and nose may appear dry. This condition can occur due to various factors such as vomiting, diarrhea, or inadequate fluid intake. Normal capillary refill (choice B) is not typically associated with dehydration; it is a measure of circulatory status. Hyperactive bowel sounds (choice C) can be present in conditions like gastroenteritis but are not specific to dehydration. Edema (choice D) is the retention of fluid in the body and is not a typical sign of dehydration.
2. What is the first sign of puberty in boys?
- A. Enlargement of testes
- B. Decreased levels of testosterone
- C. Voice deepening
- D. Pubic hair
Correct answer: A
Rationale: The first sign of puberty in boys is typically the enlargement of the testes. This is due to the increase in production of testosterone, which leads to physical changes such as growth of the testes. Choice B, decreased levels of testosterone, is incorrect as puberty is marked by an increase in testosterone levels. Choice C, voice deepening, and choice D, pubic hair growth, usually occur later in the puberty process compared to testicular enlargement, making them incorrect answers.
3. What is the most consistent and commonly used indicator of pain in infants?
- A. Increased respirations
- B. Increased heart rate
- C. Thrashing of arms and legs
- D. Facial expression of discomfort
Correct answer: D
Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.
4. What is an important intervention in providing a neutral thermal environment for an LBW infant in an incubator?
- A. Use wool blankets.
- B. Avoid using disposable diapers.
- C. Prevent heat loss.
- D. Closely monitor both incubator and rectal temperatures.
Correct answer: C
Rationale: Preventing heat loss in a low birth weight (LBW) infant is crucial in maintaining a neutral thermal environment. The use of cotton blankets is recommended over wool blankets. Avoiding disposable diapers is not directly related to maintaining a neutral thermal environment. While monitoring temperatures is important, the key intervention is preventing heat loss to ensure the infant's survival.
5. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct answer: D
Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.
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