ATI RN
Nursing Care of Children ATI
1. What is characteristic of a neonate’s vision?
- A. Pupils react to light
- B. Tear glands function
- C. Blink reflex is absent
- D. Ciliary muscles are mature
Correct answer: A
Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.
2. Which of the following is the best indicator of a child's nutritional status?
- A. Weight
- B. Height
- C. Head circumference
- D. Mid-upper arm circumference
Correct answer: D
Rationale: Mid-upper arm circumference is a good indicator of muscle mass and fat stores, reflecting a child's nutritional status. It is particularly useful in assessing malnutrition, as it is less affected by fluid retention or dehydration compared to other anthropometric measurements. Weight can fluctuate due to factors like hydration status, making it less reliable as a sole indicator of nutritional status. Height reflects growth but may not directly indicate current nutritional status. Head circumference is more related to brain growth and development rather than overall nutritional status.
3. According to Erikson’s developmental theory, toddlers need to be encouraged to become independent to successfully complete which developmental challenge?
- A. Trust vs. mistrust
- B. Industry vs. inferiority
- C. Autonomy vs. shame and doubt
- D. Initiative vs. guilt
Correct answer: C
Rationale: The correct answer is C: Autonomy vs. shame and doubt. Erikson's developmental stage for toddlers focuses on the conflict between developing a sense of independence (autonomy) and feelings of inadequacy (shame and doubt). Encouraging toddlers to explore their environment and make choices helps them build self-confidence and independence. Choices A, B, and D are incorrect because trust vs. mistrust relates to infancy, industry vs. inferiority is associated with school-age children, and initiative vs. guilt is linked to preschoolers.
4. The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?
- A. Poker chip tool
- B. Oucher Scale
- C. Faces Pain Rating Scale
- D. FLACC Behavioral Pain Assessment Scale
Correct answer: D
Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.
5. With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?
- A. 10th percentile
- B. 75th percentile
- C. 85th percentile
- D. 95th percentile
Correct answer: C
Rationale: A BMI-for-age at the 85th percentile indicates a child is at risk for being overweight, according to the National Center for Health Statistics criteria.
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