ATI RN
ATI Nursing Care of Children 2019 B
1. Which condition is most commonly associated with a 'sunset sign' in infants?
- A. Hydrocephalus
- B. Meningitis
- C. Cerebral palsy
- D. Encephalitis
Correct answer: A
Rationale: The 'sunset sign,' characterized by downward-driven eyes, is most commonly associated with hydrocephalus. This condition causes increased intracranial pressure, leading to the eyes appearing to be forced downward. Meningitis (choice B) typically presents with symptoms such as fever, headache, and a stiff neck, but not the 'sunset sign.' Cerebral palsy (choice C) is a group of disorders affecting movement and muscle coordination, not directly related to the 'sunset sign.' Encephalitis (choice D) is inflammation of the brain, which can cause symptoms like fever, headache, and confusion, but not the specific downward eye gaze seen in the 'sunset sign.'
2. The nurse is assessing a child suspected of having pinworms. Which is the most common symptom the nurse expects to assess?
- A. Restlessness
- B. Distractibility
- C. Rectal discharge
- D. Intense perianal itching
Correct answer: D
Rationale: Intense perianal itching is the most common symptom of pinworm infection, especially at night when the female worms lay their eggs
3. A child is hospitalized in acute renal failure and has a serum potassium greater than 7 mEq/L. What temporary measures that will produce a rapid but transient effect to reduce the potassium should the nurse expect to be prescribed? (Select all that apply.)
- A. Dialysis
- B. All below
- C. Sodium bicarbonate
- D. Glucose 50% and insulin
Correct answer: A
Rationale: Calcium gluconate, sodium bicarbonate, and glucose with insulin are used as temporary measures to rapidly reduce serum potassium levels. They help shift potassium into cells and stabilize the heart but do not remove potassium from the body like dialysis does.
4. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose test.” What is the purpose of this test?
- A. Deep tendon reflexes
- B. Cerebellar function
- C. Sensory discrimination
- D. Ability to follow directions
Correct answer: B
Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.
5. What is the typical presentation of pyloric stenosis in infants?
- A. Bilious vomiting
- B. Projectile vomiting
- C. Blood in stools
- D. Failure to thrive
Correct answer: B
Rationale: The correct answer is B: Projectile vomiting. Pyloric stenosis in infants typically presents with projectile vomiting, which is forceful and projective in nature. This occurs due to the obstruction at the pylorus, leading to the stomach being unable to empty properly. Choices A, C, and D are incorrect. Bilious vomiting is more commonly associated with intestinal obstruction, blood in stools can occur in conditions such as necrotizing enterocolitis or allergic colitis, and failure to thrive is a nonspecific finding that can be seen in various pediatric conditions.
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