which of the following is the best indicator of a childs nutritional status which of the following is the best indicator of a childs nutritional status
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. Which of the following is the best indicator of a child's nutritional status?

Correct answer: D

Rationale: Mid-upper arm circumference is a good indicator of muscle mass and fat stores, reflecting a child's nutritional status. It is particularly useful in assessing malnutrition, as it is less affected by fluid retention or dehydration compared to other anthropometric measurements. Weight can fluctuate due to factors like hydration status, making it less reliable as a sole indicator of nutritional status. Height reflects growth but may not directly indicate current nutritional status. Head circumference is more related to brain growth and development rather than overall nutritional status.

2. During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?

Correct answer: Report of headache

Rationale: Severe preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. Headache is a common symptom in clients with severe preeclampsia due to cerebral edema or vasospasm. Tachycardia (Choice A) is not typically associated with severe preeclampsia. Clonus (Choice B) is a sign of hyperactive reflexes, often seen in clients with severe preeclampsia. Polyuria (Choice C) is not a typical finding in clients with severe preeclampsia.

3. The nurse is caring for a client who is at risk for tumor lysis syndrome. Which laboratory value requires the nurse to intervene?

Correct answer: C

Rationale: Tumor lysis syndrome (TLS) is a potentially life-threatening condition that occurs when large numbers of cancer cells die rapidly, releasing their contents into the bloodstream. This can overwhelm the kidneys and lead to acute kidney injury. Creatinine is a waste product filtered out of the blood by the kidneys, and an elevated creatinine level is a sign of kidney dysfunction or damage. In TLS, increased creatinine levels indicate that the kidneys are struggling to filter out the excess waste products from cell breakdown, requiring immediate intervention to prevent further complications, such as acute renal failure.

4. A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

Correct answer: Continuous bubbling in the water-seal chamber

Rationale: Continuous bubbling in the water-seal chamber indicates air is leaking into the pleural space, which is a complication. The water-seal chamber should have intermittent bubbling during normal functioning. Occasional bubbling in the water-seal chamber is normal and shows the system is working as intended. Constant bubbling in the suction-control chamber suggests an issue with the suction control. Fluctuations in the fluid level in the water-seal chamber are an expected finding.

5. A nurse is teaching an in-service about manifestations of hypoglycemia to a group of newly licensed nurses. Which of the following should the nurse include in the teaching?

Correct answer: A

Rationale: Blurred vision is a common symptom of hypoglycemia and should be included in the teaching.

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