ATI RN
ATI Nursing Care of Children 2019 B
1. What is the first step in managing a child with anaphylaxis?
- A. Administer antihistamines
- B. Establish IV access
- C. Administer epinephrine
- D. Monitor vital signs
Correct answer: C
Rationale: The correct answer is to administer epinephrine. Administering epinephrine is the crucial first step in managing anaphylaxis as it helps reverse the severe allergic reaction by constricting blood vessels and relaxing airway muscles, preventing a life-threatening situation. Antihistamines (Choice A) are not the first-line treatment for anaphylaxis and should not delay the administration of epinephrine. Establishing IV access (Choice B) may be necessary but is not the initial step in managing anaphylaxis. Monitoring vital signs (Choice D) is important but should not take precedence over administering epinephrine in the acute management of anaphylaxis.
2. A toddler’s mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse’s response should be based on which premise?
- A. An emergency laparotomy is very likely.
- B. The location needs to be confirmed by radiographic examination.
- C. Surgery will be necessary if the battery has not passed in the stool in 48 hours.
- D. Careful observation is essential because an ingested battery cannot be accurately detected.
Correct answer: B
Rationale: Radiographic examination is essential to confirm the location of the battery, as it can cause significant damage, particularly if lodged in the esophagus. Immediate surgery may be required depending on its location and the potential for causing harm.
3. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)
- A. All below
- B. A well-defined light reflex
- C. A small, round, concave spot near the center of the drum
- D. The tympanic membrane is a nontransparent grayish color
Correct answer: A
Rationale: A well-defined light reflex, a small concave spot, and a grayish, nontransparent tympanic membrane are normal findings during an otoscopic examination in a child.
4. The school nurse understands that children are impacted by divorce. Which has the most impact on the positive outcome of a divorce?
- A. Age of the child
- B. Gender of the child
- C. Family characteristics
- D. Ongoing family conflict
Correct answer: D
Rationale: The level of ongoing family conflict is the most significant factor influencing the positive or negative outcomes for children during and after a divorce
5. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?
- A. S1 and S2
- B. S3 and S4
- C. Murmur
- D. Physiologic splitting
Correct answer: C
Rationale: A murmur is produced by turbulent blood flow within the heart or major arteries, resulting in audible vibrations.
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