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. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct answer: C
Rationale: Providing a simple explanation satisfies the child's curiosity and helps reduce any anxiety about the procedure.
3. What amount of fluid loss occurs with moderate dehydration?
- A. <50 ml/kg
- B. 50 to 90 ml/kg
- C. <5% total body weight
- D. >15% total body weight
Correct answer: B
Rationale: Moderate dehydration is typically defined as a loss of 50 to 90 mL/kg of body weight. This amount reflects significant fluid loss that requires medical attention but is not yet severe.
4. Which congenital heart defect causes a "boot-shaped" heart on a chest x-ray?
- A. Tetralogy of Fallot
- B. Coarctation of the aorta
- C. Transposition of the great arteries
- D. Ventricular septal defect
Correct answer: A
Rationale: The correct answer is A: Tetralogy of Fallot. Tetralogy of Fallot, a congenital heart defect with four distinct abnormalities, often presents with a "boot-shaped" heart on chest x-ray due to right ventricular hypertrophy. This characteristic finding is due to the specific combination of defects in this condition. Coarctation of the aorta (choice B), Transposition of the great arteries (choice C), and Ventricular septal defect (choice D) do not typically result in a "boot-shaped" heart on a chest x-ray like Tetralogy of Fallot does.
5. Which dietary information should the nurse include in the teaching plan for a school-age child with chronic renal failure?
- A. High in sodium
- B. Low in Vitamin D
- C. Low in phosphorus
- D. Supplementation of vitamins C, E, K
Correct answer: C
Rationale: A low-phosphorus diet is recommended for children with chronic renal failure to prevent hyperphosphatemia, which can lead to bone disease and other complications. Phosphorus is found in many processed foods and should be limited. Choices A, B, and D are incorrect because high sodium intake can lead to fluid retention and hypertension, while Vitamin D supplementation and vitamins C, E, K are not specifically indicated for dietary recommendations in chronic renal failure.
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