ATI RN
ATI Nursing Care of Children 2019 B
1. Which of the following is a hallmark sign of intussusception in children?
- A. Bilious vomiting
- B. "Currant jelly" stools
- C. Abdominal distention
- D. Constipation
Correct answer: B
Rationale: "Currant jelly" stools, consisting of mucus and blood, are characteristic of intussusception in children. It occurs due to the telescoping of a segment of the intestine into an adjacent segment, leading to obstruction and subsequent mucosal ischemia, causing the passage of bloody mucus in the stool. Bilious vomiting can be seen in other conditions like bowel obstruction, abdominal distention can be present but is not as specific, and constipation is less likely in the presentation of intussusception.
2. What is most important in the management of cellulitis?
- A. Burow solution compresses
- B. Oral or parenteral antibiotics
- C. Topical application of an antibiotic
- D. Incision and drainage of severe lesions
Correct answer: B
Rationale: Oral or parenteral antibiotics are essential in treating cellulitis to eliminate the infection. Topical antibiotics are not sufficient, and incision and drainage are only for abscesses.
3. Which assessment findings should the nurse expect in a child with sickle cell anemia experiencing an acute vaso-occlusive crisis?
- A. Circulatory collapse, hypovolemia
- B. Cardiomegaly, systolic murmur
- C. Hepatomegaly, intrahepatic cholestasis
- D. Painful swelling of joints in hands and feet, tissue engorgement
Correct answer: D
Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia are characterized by painful swelling of the joints in the hands and feet (hand-foot syndrome) and tissue engorgement due to the obstruction of blood flow by sickled cells. Choices A, B, and C are incorrect because circulatory collapse, hypovolemia, cardiomegaly, systolic murmur, hepatomegaly, and intrahepatic cholestasis are not typically associated with an acute vaso-occlusive crisis in sickle cell anemia.
4. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.
5. The nurse is assisting a child with celiac disease to select foods from a menu. What foods should the nurse suggest?
- A. Hamburger patty with no bun
- B. Spaghetti with marinara sauce
- C. Corn on the cob with butter
- D. Rice cakes with hummus
Correct answer: C
Rationale: The correct answer is C: Corn on the cob with butter. Corn is a gluten-free option suitable for children with celiac disease. Choice A is incorrect because the bun contains gluten, so suggesting a hamburger patty without the bun is a better option. Choice B is not ideal as spaghetti often contains gluten, but spaghetti with marinara sauce could be a safer choice if the spaghetti is gluten-free. Choice D, rice cakes with hummus, is a gluten-free alternative, but corn on the cob is a more straightforward and common choice for children.
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