which best describes signs and symptoms as part of a nursing diagnosis

ATI RN

Nursing Care of Children Final ATI

1. Which best describes signs and symptoms as part of a nursing diagnosis?

A. Description of potential risk factors
B. Identification of actual health problems
C. Human response to state of illness or health
D. Cues and clusters derived from patient assessment

Correct answer: D

Rationale: Signs and symptoms are cues and clusters derived from patient assessments that are used to form a nursing diagnosis, guiding the development of a care plan.

2. A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?

A. Reassure the father that Visine is harmless.
B. Direct him to seek immediate medical treatment.
C. Recommend inducing vomiting with ipecac.
D. Advise him to dilute Visine by giving his daughter several glasses of water to drink.

Correct answer: B

Rationale: Visine is not harmless when ingested, and immediate medical treatment is necessary due to the risk of toxicity. Vomiting should not be induced without medical advice, and dilution with water is not an appropriate treatment.

3. The nurse is caring for a child with Beta Thalassemia. Which child is in a group most at risk for Beta Thalassemia?

A. A three-year-old girl of Mediterranean descent.
B. A ten-year-old boy of Hispanic descent.
C. A young girl of African descent.
D. A baby of European descent.

Correct answer: A

Rationale: Corrected Rationale: Beta Thalassemia is most common in individuals of Mediterranean descent, such as those from Italy, Greece, and the Middle East. This genetic disorder affects hemoglobin production and can lead to severe anemia. Choice A is the correct answer as individuals of Mediterranean descent are at the highest risk for Beta Thalassemia. Choices B, C, and D are incorrect as they do not belong to the population group most at risk for this genetic disorder.

4. Which statement best describes colic?

A. Periods of abdominal pain resulting in weight loss
B. Usually the result of poor or inadequate mothering
C. Periods of abdominal pain and crying occurring in infants older than age 6 months
D. A paroxysmal abdominal pain or cramping manifested by episodes of loud crying

Correct answer: D

Rationale: Colic is characterized by episodes of loud, inconsolable crying, often due to abdominal discomfort, and typically occurs in infants younger than 6 months. It is not related to poor mothering, nor does it necessarily result in weight loss.

5. Parents of a child who will need hemodialysis ask the nurse, What are the advantages of a fistula over a graft or external access device for hemodialysis? (Select all that apply.)

A. It is ready to be used immediately.
B. All below
C. There is less restriction of activity with a fistula.
D. It produces dilation and thickening of the superficial vessels.

Correct answer: A

Rationale: A fistula typically has fewer complications, allows for greater freedom of movement, and involves natural vessel changes that improve dialysis efficiency. However, it is not ready for immediate use, which is why it may take weeks to mature before it can be used.