ATI RN
RN Nursing Care of Children 2019 With NGN
1. What statement best describes Hirschsprung disease?
- A. The colon has an aganglionic segment.
- B. It results in frequent evacuation of solids, liquid, and gas.
- C. The neonate passes excessive amounts of meconium.
- D. It results in excessive peristaltic movements within the gastrointestinal tract.
Correct answer: A
Rationale: Hirschsprung disease is characterized by the absence of ganglion cells in a segment of the colon, leading to a lack of peristalsis and obstruction. The other options do not accurately describe this condition.
2. Which explains the importance of detecting strabismus in young children?
- A. Color vision deficit may result.
- B. Amblyopia, a type of blindness, may result.
- C. Epicanthal folds may develop in the affected eye
- D. Corneal light reflexes may fall symmetrically within each pupil
Correct answer: B
Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.
3. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?
- A. Fear of strangers
- B. Minimal smiling
- C. Avoidance of eye contact
- D. All of the above
Correct answer: D
Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.
4. When assessing a child with chronic renal failure, which clinical manifestations would the nurse expect to find?
- A. Uremic frost
- B. Hypotension
- C. Massive hematuria
- D. Severe metabolic acidosis
Correct answer: A
Rationale: When assessing a child with chronic renal failure, the nurse would expect to find uremic frost as a clinical manifestation. Uremic frost, a white powdery deposit of urea on the skin, occurs in severe cases of chronic renal failure due to the accumulation of urea and other waste products in the blood. Hypotension and massive hematuria are less common in chronic renal failure, while severe metabolic acidosis is typically mild to moderate and not a prominent clinical manifestation.
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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