ATI missed questions wk 6 - Madison Gardner

C Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment

A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? a. preschoolers have the highest rates of maltreatment b. in single-parent families, the parent's non-biological partner is typically the abuser of the child c. children who were born prematurely are more likely to be maltreated d. child maltreatment occurs equally across all socioeconomic groups

B The nurse should expect an 8 month old infant to have a heightened fear of strangers. The infant is expected to cling to her parent and turn away when approached by a stranger

A nurse in a provider's office enters an exam room to assess an 8 month old infant for the first time. Which of the following reactions by the infant should the nurse expect? a. the infant gives the nurse a social smile b. the infant turns away when the nurse approaches c. the infant reaches out to the nurse to be held d. the infant is responsive and alert as the nurse comes closer

A The nurse should explain that the extrusion reflex results in food being pushed out of the mouth instead of being swallowed. The tongue extrusion reflex diminishes after 4 months of age

A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include? a. begin after the extrusion reflex has diminished b. introduce solids between 2-3 months of age c. wait until the infant's first tooth erupts d. add a sweetener such as light corn syrup to bland foods

a, e, f, g

Select 4 actions the nurse should implement for the adolescent a. provide education about dialysis b. administer intermittent liter bolus of IV fluid c. check blood glucose before meals and at bedtime d. initiate contact isolation precautions e. encourage intake of dietary protein f. obtain daily weights g. provide teaching about taking phosphate binders h. insert nasogastric tube for decompression

c, d, e,

The nurse is evaluating the toddler at the follow-up appointment. Which findings in the toddler's electronic medical record indicate the toddler is experiencing a complication related to their diagnosis a. temp 99.1 F b. respiratory rate 28/min c. the toddler vomited twice this am d. abdomen distended; bowel sounds hypoactive e. last bowel movement 1 week ago f. toddler has gained 1 kg since last visit g. capillary refill less than 2 seconds

a. expected b. expected c. not expected d. not expected e. expected

The nurse is planning care for the infant. For each potential provider prescription, specify if the prescription is expected or unexpected for the infant. a. apply a urine collection bag to infant to measure urine specific gravity b. administer dexamethasone 0.75mg IV once c. administer ganciclovir 30 mg IV every 12 hr d. obtain weight weekly e. administer 0.9% sodium chloride with 5% dextrose IV at 20ml/hr

b, b When prioritizing hypothesis for an infant who has bacterial meningitis, the nurse should first place the infant on droplet precautions, then initiate seizure precautions.

complete the following sentence by using the lists of options. Upon review of the suspected diagnosis and provider prescriptions, the nurse should first _____________ a. b. place the infant on droplet precautions c. , then ___________________ a. b. initiate seizure precautions c.

Cystic fibrosis a,b,c,d Asthma a Tuberculosis a, d

for each assessment finding specify if the finding is consistent with cystic fibrosis, asthma or tuberculosis a. presence of cough b. parent report of stool findings c. parent report of integumentary findings d. weight

Anemia b, d Acute glomerulonephritis b, c, d Chronic kidney disease a, b, c, d

for each finding specify if the finding is consistent with anemia, acute glomerulonephritis or chronic kidney disease a. urine color b. skin color c. blood pressure d. headache

D a 6 month old infant should be able to turn over completely, sit momentarily without support, and reach to be picked up

A nurse is assessing a 6 month old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? a. sitting alone b. attempting to stack objects c. picking up small objects with a crude pincer grasp d. turning from back to stomach

B The nurse should check the infant's ability to see by positioning the infant upright and holding a brightly colored toy or object in front of the infant's face and moving it from side to side. The nurse should observe the infant's ability to fixate on the toy and track its movement. The nurse can also perform this assessment using the human face as a visual target

A nurse is assessing a 6 month old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infant's visual acuity? a. shine a penlight briefly into the left eye and then the right eye b. move a brightly colored toy from side to side in front of the infant's face c. ask the guardian to sit in front of the infant and nod his head up and down d. observe the infant's ability to grasp the feet and pull them to the mouth

A when applying the urgent v nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight.

A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority a. measure the client's weight daily b. check for tears c. palpate the fontanel d. assess skin turgor

C the nurse should encourage the parent to include the use of manual jaw control during feedings. Children diagnosed with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to the jaws during feeding

A nurse is creating a plan of care for an 18 month old toddler who has cerebral palsy. Which of the following interventions should the nurse include? a. use a mobile walker for the toddler b. discourage activities involving repetitive joint movement c. use manual jaw control when feeding the toddler d. discourage the use of wrist splints

A the nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short-bowl syndrome, lactose intolerance, and congenital enzyme deficiency

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? a. celiac disease b. ulcerative colitis c. Hirschsprung's disease d. chron's disease

D Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age

A nurse is emergency department is caring fora n 8 year old who is up-to-date with current immunization recommendation and has a deep puncture injury. Which of the following should the nurse anticipate administering? a. DTap b. TIG c. Tdap D. Td

a, b, c, d, e, h

Which findings require further evaluation by the nurse. a. parent report the toddler eats well but doesn't gain weight b. states the toddler has huge, frothy stools that smell terrible c. parent reports the toddler's skin tastes salty when they kiss them d. barrel shaped appearance to chest e. breath sounds diminished diffusely throughout lung fields f. s1, s2 auscultated, no murmur g. abdomen soft, nontender h. toddler has lost 1.4 kg since their office visit 6 months ago

C A bp of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? a. temp 99.5F b. apical pulse rate 140/min c. bp 86/40 d. respiratory rate 32/min

D The nurse should expect a 3 year old child to have the gross motor ability to stand on 1 foot for a few seconds

A nurse is assessing the development of a 3 year old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? a. skipping around the room b. hopping on 1 foot c. throwing a ball overhead d. standing on 1 foot

B paralytic poliomyelitis presents with pain and stiffness in the back, neck and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause the child discomfort.

A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? a. implement droplet precautions b. administer oral analgesics prior to exercises c. use humidified oxygen to thin secretions d. initiate seizure precautions

C The expected reference range for a toddler is a creatinine level of 0.3-0.7 mg/dL. The child's level is above the expected reference range and should be reported to the provider.

A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider. A.BUN 8 mg/dL B. Uric acid 3.0 mg/dL C. Creatinine 0.9 mg/dL D. Urine specific gravity 1.010

B The developmental task of industry v inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (6-12 years)

A nurse is performing a well-child assessment on a 7 year old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? a. initiative v guilt b. industry v inferiority c. identity v role confusion d. autonomy v shame and doubt

B a cooling blanket will lower the temp of the blood circulating at the skin's surface. This cooler blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface.

A nurse is planning care for a child who has hyperthermia. which of the following actions should the nurse take? a. administer antipyretics to the child every 4-6 hr b. position the child on a cooling blanket and cover her with a sheet c. place the child in a tub filled with water cooled to 80-85 F d. assess the child's temp every 2 hr during the cooling process

C a neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distention due to the possibility of incomplete emptying of the bladder

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? a. fasten the diaper loosely b. cleanse the meningeal sac with povidone-iodine daily c. palpate the abdomen for bladder distension d. cover the sac with a dry, sterile gauze dressing

a, c, d

A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? a. my child will likely be irritable for the next few weeks b. i will notify my child's doctor if the skin on her hands or feet begins to peel c. i will ensure my child does not receive any live vaccines for at least 18 d. i will keep a record of my child's temperature until she has no fever for several days e. my child will have joint stiffness primarily at the end of the day

a, c, e

A nurse is teaching the adolescent and their parents about the prescribed therapeutic procedure. Which of the following statements should the nurse make? a. a temporary access catheter will be placed in the vein on the side of your neck b. there is a risk of developing peritonitis c. the procedure will take about 3-5 hours to complete d. the procedure is performed 3 times per day e. the procedure filters waste products from your blood through a machine f. a fistula will be inserted in your arm today

D the nurse should plan to administer albuterol to a child who is experiencing an acute exacerbation of asthma. This is considered a rescue medication due to its rapid onset of action. Albuterol is a beta-adrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs

A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child? a. zafirlukast b. budesonide c. montelukast d. albuterol

bacterial meningitis a, b, c, d, e febrile seizure c UTI a, b, c When analyzing cues, the nurse should recognize that the infant is experiencing bacterial meningitis. The assessment finding of an elevated temperature, poor feeding pattern, bulging and tense fontanel, high-pitched cry, and level of consciousness findings of irritability and lethargy are manifestations of bacterial meningitis in an infant. The assessment finding of an elevated temperature is a manifestation of febrile seizure. The assessment findings of an elevated temperature, poor feeding pattern, level of consciousness, and findings of irritability and lethargy are manifestations of a urinary tract infection in an infant

For each assessment finding, specify if the finding is consistent with bacterial meningitis, febrile seizure, or urinary tract infection. Each finding may support more than 1 disease process or none at all. a. level of consciousness b. feeding pattern c. temperature d. crying pattern e. fontanels

a, b, c, e, g, h, i When recognizing cues, the nurse should identify that the assessment finding of irritability, poor feeding, a bulging and tense fontanel, a high-pitched cry, cool extremities, fever, and lack of immunizations should be reported to the provider immediately. Irritability, poor feeding, a high-pitched cry, and a bulging and tense fontanel are manifestations of increased intracranial pressure. The findings of fever and cool extremities are manifestations of infection. Lack of immunizations to certain pathogens can place the infant at risk for bacterial meningitis

Which of the following assessment findings should the nurse report to the provider immediately? a. infant was irritable b. had not been feeding well c. high-pitched cry noted d. posterior fontanel closed e. anterior fontanel is open, bulging, and tense f. S! and S2 with sinus arrhythmia noted g. extremities cool to touch h. the infant has not had immunizations since birth i. temp 39 C (102.2 F) j. blood pressure 85/50

b, c

Which of the following statements by the parent indicates an understanding of the potential long-term complications of bacterial meningitis? Select the 2 statements that indicate an understanding a. my baby will probably have chronic renal failure as they get older b. i may notice behavioral issues when my infant gets older c. this could cause learning difficulties d. my baby could develop vision loss e. even though my baby had a seizure this will not lead to a seizure disorder