ATI RN
ATI Nursing Care of Children
1. In assessing sexual maturity levels, which tool would you expect to use?
- A. Denver II Developmental Screening
- B. Tanner staging
- C. Antibody testing
- D. Nursing process
Correct answer: B
Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.
2. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?
- A. Flush the tube with 100 mL of water
- B. Verify tube placement
- C. Elevate the head of the bed
- D. Measure the residual gastric volume
Correct answer: B
Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.
3. You organize community groups to participate in the community activities. You can BEST motivate to participate in community health development program by:
- A. Conducting group works
- B. Instructing the people to agree with your plans
- C. Allowing the people to exercise decision-making
- D. Assigning people participative roles
Correct answer: C
Rationale: Allowing people to exercise decision-making empowers the community and fosters greater participation and ownership of health initiatives.
4. A healthcare provider is caring for a client who has a new prescription for Digoxin. Which of the following findings should the healthcare provider identify as a potential sign of Digoxin toxicity?
- A. Nausea
- B. Dry mouth
- C. Hypoglycemia
- D. Tinnitus
Correct answer: A
Rationale: Nausea is a potential sign of Digoxin toxicity. Along with vomiting, visual disturbances, and confusion, it can be an early indication of an overdose. Dry mouth is not typically associated with Digoxin toxicity. Hypoglycemia is a low blood sugar level and is not directly related to Digoxin toxicity. Tinnitus, a ringing in the ears, is not a common sign of Digoxin toxicity. Healthcare providers should closely monitor clients on Digoxin for symptoms like nausea to prevent serious complications.
5. Identifying the strengths and weaknesses in the plan of nursing care is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: A
Rationale: The correct answer is A: Evaluation. Evaluation in nursing care involves assessing the effectiveness of the care plan, identifying strengths, weaknesses, and areas for improvement. This step helps ensure that the patient's needs are being met appropriately. Planning (choice B) involves developing the care plan based on the assessment data. Implementation (choice C) is the step where the care plan is put into action. Assessment (choice D) is the initial step in the nursing process that involves collecting and analyzing data about the patient's health status.