ATI assessment B pediatrics PDF

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This document is ATI pediatrics assessment B answers with rationals...

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1. A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. Great Toe. The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. 2. A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the bicep reflect. a. Up the elbow on your thumb side, the opposite is triceps, and under the wrist on thumb side is brachioradialis reflex 3. A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? a. "I will teach challenging academic subjects to students who have ADHD in the morning." Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective. 4. A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe. a. Recombinant growth hormone: Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. b. Luteinizing hormone relieasing hormone treats precocious puberty 5. A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? a. Serum potassium level 4.1 mEq/L, The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. Diarreah is the a/e 6. A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take? a. Place the infant in a knee-chest position: The nurse should place the infant in a kneechest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. b. The nurse should administer morphine to decrease spasms, oxygen at 100% via face mask, continue fluid IV. 7. A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a. Palpate the dorsum of the childs feet: The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema. 8. A nurse is planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. Use a semipermeable transparent dressing to cover the site: The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. b. Also flush catheter with heparin daily when not in use

9. A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? a. I should wear sandals as much as possible.": Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or wellventilated shoes will promote healing of the fungal infection. b. Permethrin cream is for scabicide, sealing nonwashable item In plastic bag for 14 days is for pediculosis. 10. A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurses priority? a. Disease process: The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration 11. A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which if the following instructions should the nurse include in the teaching? a. Encourage the child to perform independent self-care.": The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. b. Large joint should be exercised regularly, sleep on firm mattress, daytime nap is discouraged because stiffness occurs quickly with inactivity. 12. nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature a. Dress the toddler in minimal clothing.: The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature. b. Do not apply a cooling blanket, tepid bath is lukewarm is may cause discomfort so that is indicated for hyperthermia. 13. nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? a. FACES: The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management. b. Numeric is for 8 and older, cries is for less than 40 weeks, visual analog is for greater than 8 14. A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a. Decreased edema: A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema. b. Also decreased protein in urine, decreased abd grith, increased appetite 15. A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? a. Avoid palpating the abdomen when bathing the child before surgery.: The nurse should avoid palpating the abdomen when bathing the child before surgery because movement

of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. Also decrease activity. 16. A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching a. "Award your child with a sticker when they sit on the potty chair.": A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair. 17. A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "I will notify the doctor if I notice that my child is swallowing frequently." b. Do not gargle with salt, not milk products, limit activity 18. A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? a. Deep respirations of 32/min: The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis. b. Shallow respiration is seen with opioid, paradoxic respiration with flail chest and apnea with sleep apnea 19. A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? a. Expressed likes and dislikes: The nurse should include that expressing likes and dislikes is an expected behavior of toddlers b. Understanding right from wrong is preschooler and controlling impulsive feelings is for school age 20. A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take a. Have the adolescent sign a consent form for treatment.: The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent. 21. A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? a. "Wait 3 days before taking a tub bath.": The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water b. The child can return to school the next day, can resume regular diet after procedure, pressure dressing should be removed the day after an apply adhesive bandage daily for the next 2 days. 22. A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? a. Nasal flaring: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress.

23. A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistant asthma. Which of the following instructions should the nurse include? a. Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy.": The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly. 24. Initiate airborne precautions for the child.: The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear. 25. A nurse is providing discharge teaching to the guardians of a toddler who had lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following finding to the provider? a. Restricted ability to move the toes.: The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours. b. Swelling of the casted foot when the leg is dependent is expected. They should rest for the next several days and the foot should not be in a dependent position for more than 30 min. should be elevated on pillow at chest level. 26. A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.) a. -Vomiting, and -Lethargy. Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake. b. Also bloody stool like jelly, diarrhea, and weight loss. 27. A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will monitor my childs number of wet diapers.": The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. Polyethylene glycol will increase dehydration level. Encourage solid food as soon as rehydrated. You don’t have to wait til diarrhea stops 28. A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? a. "Brush the childs teeth after giving the medication.": this is to prevent tooth decay. The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. 29. A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first?

a. A toddler who has a concussion and an episode of forceful vomiting.: When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion. 30. A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? a. Sodium 155 mEq/L: A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. b. Urine specific gravity 1.005-1.030, urine output 33-58ml/hr is expected range 31. nurse is planning n educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. "Choose a waterproof sunscreen with a minimum SPF of 15.": The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. b. Should dress children in tight weave cotton fabric, and reapply sunscreen every 2-3hr 32. A nurse in a providers office is caring for a school-age child who has varicella. The parents asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. "When your childs lesions are crusted, usually 6 days after they appear.": The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days. 33. Bright light or flashing can trigger seizure. Like video game. 34. A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? a. Wheezes: The nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. b. Crackles: high pitched short and non continuous sound at the end of inspiration c. Pleural friction rub: loud, rough, grating sound during inspiration or expiration d. Rhonci: low pitched continuous sounds that have snore like quality and louder during expiration 35. A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. Presence of strabismus: Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider. 36. A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first? a. Check the childs respiratory rate.: When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths. b. They should also check for bleeding cos they bite the tongue and check for head injury but after respiration

37. A nurse is an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? a. Monitor the childs oxygen saturation: The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. b. Do not obtain throat culture until airway is established, administer humidified oxygen by face mask rather than placing a warm mist humidifier in the room, no supine 38. A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infants pain? a. Allow the mother to breastfeed while the sample is being obtained.: The nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidencebased practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants. 39. A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a. The child should be able to stand on the balls of their feet when sitting on the bike.: To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar. 40. A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a. Potassium Chloride: The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia. b. Ace inhibitor, diuretics, and insulin are ok. Insulin for hyperkalemia which is a manifestation of HF. 41. A nurse is providing discharge teaching to the parent...