while making rounds the nurse observes the following client behaviors which child should the nurse further evaluate for postoperative pain

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?

A. The 6-month-old in deep sleep
B. The 2-year-old who is cooperative when the nurse takes vital signs
C. The 4-year-old who is actively watching cartoons
D. The 14-month-old who is screaming and thrashing his arms and legs

Correct answer: D

Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.

2. What is a key distinguishing feature of bronchiolitis in infants?

A. Dry cough
B. Wheezing
C. Stridor
D. Productive cough

Correct answer: B

Rationale: The correct answer is B: Wheezing. Wheezing is a key distinguishing feature of bronchiolitis in infants, typically caused by respiratory syncytial virus (RSV) infection. Bronchiolitis is characterized by inflammation and mucus buildup in the small airways of the lungs, leading to wheezing sounds during breathing. Choices A, C, and D are incorrect because dry cough, stridor, and productive cough are not typical features of bronchiolitis in infants.

3. How is masturbation in the pre-school child viewed?

A. Abnormal behavior that needs to be dealt with immediately
B. Disruptive to the family
C. Normal behavior that can best be dealt with by ignoring and providing distraction
D. Embarrassing to the parents

Correct answer: C

Rationale: Masturbation in preschool children is a normal behavior as they explore their bodies. It is best viewed as a natural part of development. Parents are often advised to ignore it and provide distractions rather than making the child feel ashamed or embarrassed. Choice A is incorrect because it is a natural behavior and not considered abnormal in this context. Choice B is incorrect as it does not necessarily disrupt the family. Choice D is incorrect as the focus should be on the child's development and well-being, not on the parents' feelings of embarrassment.

4. The nurse is aware that which age group is at risk for childhood injury because of the cognitive characteristic of magical and egocentric thinking?

A. Preschool
B. Young school age
C. Middle school age
D. Adolescent

Correct answer: A

Rationale: Preschool children are at higher risk for injury due to magical and egocentric thinking, which can lead to misjudgments about their abilities and dangers.

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.