ATI Practice A

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?

Denies discomfort during assessment of injuries The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.

A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

Hgb 8.5 g/dL A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control?

Have a designated stethoscope in the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?

Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider. EXPECTED findings meningitis: headache, nuchal rigidity, positive Kernig's sign

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?

Schedule the toddler for a yearly rescreening. The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.

A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?

Substernal retractions 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 substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?

Playing dress-up The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child. pat-a-cake = infant push-pull toys = toddler scrapbooking = school-age

History and Physical​ Age 15 months Height 71.1 cm (28 in) Allergies Neomycin (anaphylactic reaction) Caregiver reports rhinitis with clear nasal drainage for 2 days Occasional nonproductive cough for 2 days History of asthma A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area?

Zinc oxide Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?

Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child. avoid nasal suctioning due to the risk of exposure of the suction catheter to the brain through the fracture

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?

"I will give myself a shot of regular insulin 30 minutes before I eat breakfast." The child should administer regular insulin 30 min before meals so that the onset coincides with food intake. also: puncture skin on SIDE OF FINGERPAD and not the pad itself because there are fewer blood cells and more nerve fibers in the finger pad, eat a snack of 10-15 g carbs to increase blood glucose, increase fluid intake when sick

A nurse is caring for a 15-year-old client who is married and is scheduled for a surgical procedure. The client asks, "Who should sign my surgical consent?" Which of the following responses should the nurse make?

"You can sign the consent form because you are married." The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age. Therefore, adolescents who are married do not require consent of a parent.

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first?

A school-age child who has sickle cell anemia and reports decreased vision in the left eye When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first. frequent non productive cough is expected in cystic fibrosis, sensitivity to light is an expected and non urgent finding in meningitis

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?

Administer the immunization using a 24-gauge needle. The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences. also: place child in upright position to reduce anxiety, allow caregiver to stay near child, inject rapidly and avoid aspiration

A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?

Initiate droplet precautions for the child. The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

White rice The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?

cuts out shape using scissors at 4 yo 6 yo - identifies from right to left and uses utensils 5 yo - draws stick figure with seven body parts

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?

Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity. Hgb = 9.5 to 14 school aged child wbc and platelets same as adult

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?

"I should secure the car seat using lower anchors and tethers instead of the seat belt." Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used. also: the seat harness in rear-facing seats should be positioned at or just below the infant's shoulders, car seat should be 45 degree angle, no extra padding is to be used

Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child. regarding the 4 year old coming in from a house fire

Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas is contraindicated. Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contamination and hypothermia. Insert an indwelling urinary catheter is anticipated. Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. It is important to maintain accurate hourly I&O to manage fluid replacement. Provide 100% oxygen via face mask is anticipated. Upon admission to the emergency department, the nurse should recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range and their respiratory rate is increased. Weigh the child is anticipated. The nurse should recognize the need to weigh the child as essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

Respiratory rate 45/min The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider. also, normal ranges for 3 year old: 86 to 118 systolic and 44 to 74 diastolic 32 lb average weight 80 - 120 bpm HR

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?

Screen the child's visitors for indications of infection. A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection.

A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?

Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. other findings in spinal fluid associated with bacterial meningitis: decreased glucose, increased WBC, and increased cerebrospinal fluid pressure

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?

Provide small, frequent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy. also: restrict play activities to minimize energy expenditure, weight daily, semi-fowler's position in bed

After reviewing the information in the medical record, the nurse should identify that the child is at risk for developing which of the following conditions?

Splenomegaly is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Positive mononucleosis rapid test is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis.

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurse's priority?

Tachypnea When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis. tachypnea takes priority over hypotension

A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?

The toddler received tobramycin during a hospitalization 2 weeks ago. The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?

"Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating. because preschoolers do not have an accurate understanding of time

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?

Symmetric burns of the lower extremities The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron. recurrent UTIs can indicate sexual abuse failure to thrive can indicate neglect lack of subq fat can indicate physical neglect

Select 6 statements by the parent that indicate an understanding of the discharge teaching.

"I should apply a moisturizer to the scar tissue" is correct. Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching the child might experience. "I will use a measured spoon or medicine cup to give my child hydroxyzine" is correct. All liquid medications should be administered with a measured spoon or cup to provide an accurate amount of the prescribed dose of medication. "I can give my child hydroxyzine every 6 hours as needed" is correct. Hydroxyzine is administered every 6 to 8 hr each day as needed. "Puppet play can be helpful for my child" is correct. Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings through imaginary play. "I need to assess for any redness or open skin areas before applying my child's left arm splint" is correct. It is important that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to prevent contractures of the extremities and promote normal alignment during the healing process. Because the splint might be worn for a long period of time, the child's growth might cause the splint to not fit properly and can cause a pressure injury. "My child will need to use a compression garment to decrease blood supply to the scarred tissue" is correct. Using a compression garment on the scar tissue decreases the blood supply to avoid nourishing the hypertrophic tissue. It also forces the collagen into a more normal alignment. Compression garments are worn during the healing of the burned tissue and should be worn as much as possible.

A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take?

Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?

Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?

Initiate seizure precautions for the child. A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety. also: NO NSAIDs, blood pressure every 4-6 hours, and weigh daily

A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?

"Give the infant a pacifier at bedtime." The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping. prone position when sleeping on a firm mattress

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?

Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

Nurses' Notes 0915:Guardians report that lately the child has had severe itching and is breaking out with sores on their eyebrows, wrists, and ankles. The "sores started to bleed." Guardians report no relief with application of the topical hydrocortisone cream. 0930:Child is alert. Multiple small erythematous papules with some scaling noted on the child's eyebrows, forearms, and lower legs bilaterally. 1015:Provider in to evaluate the child. Discharge to home after medication administration of new prescriptions and discharge teaching for atopic dermatitis.

"We should apply a skin emollient immediately after bathing our child" is correct. An emollient is an oil that moisturizes the skin and should be applied immediately after bathing while the skin is damp to prevent drying. Therefore, this statement by the guardian indicates the teaching has been effective. "We should keep our child's fingernails trimmed short" is correct. The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. Therefore, this statement by the guardian indicates the teaching has been effective. "We should rub the sores vigorously to remove scabs" is incorrect. The sores or lesions should be patted dry after bathing, rather than scrubbed vigorously. The scabs should not be removed because this could cause infection. Therefore, this statement by the guardian indicates the need for further teaching. "We should allow our child to take a bubble bath prior to bed" is incorrect. The use of bubble baths and powders should be avoided because this can cause skin irritation. Therefore, this statement by the guardian indicates the need for further teaching. "We should use a mild detergent for our laundry" is correct. The use of mild detergents for laundry helps prevent allergens and itching. Therefore, this statement by the guardian indicates the teaching has been effective. "We should apply a large amount of the ointment to the sores" is incorrect. Tacrolimus is a topical steroid that should only be applied in a thin layer. Therefore, this statement by the guardian indicates the need for further teaching.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?

Negative Babinski reflex is incorrect. The nurse should expect a child who has spastic cerebral palsy to exhibit a positive Babinski reflex. Ankle clonus is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed. Exaggerated stretch reflexes is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes. Uncontrollable movements of the face is incorrect. The nurse should expect a child who has nonspastic (dyskinetic) cerebral palsy, rather than spastic (pyramidal) cerebral palsy to exhibit uncontrollable movements of the face and extremities. Contractures is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?

A unilateral rib hump When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespiratory rate 32/minBlood pressure 100/52 mm HgSaO2 89% on room air The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up.

Partial- and full-thickness burns to the left upper anterior chest and anterior neck is correct. Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate follow-up due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. SaO2 89% on room air is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. Heart rate 150/min is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the child's increased heart rate. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock due to fluid loss. Temperature 37.7° C (99.9° F) is incorrect. Airway, breathing, and circulation are the immediate concerns. A temperature of 37.7° C (99.9° F) is within the expected reference range and does not require immediate follow-up. The child's temperature will need to be monitored closely for hypothermia and hyperthermia. Blood pressure 100/52 mm Hg is incorrect. Airway, breathing, and circulation are the immediate concerns. A blood pressure of 100/52 mm Hg is within the expected reference range for a 4-year-old child and does not require immediate follow-up. Most children have the ability to compensate and can maintain their blood pressure in the early stages of shock.

The child has returned to the unit following the procedure. Which of the following actions should the nurse take? Select all that apply. O2 = 88% room air Resp. rate = 14 / min Temp. = 96.4F Neck and left anterior chest dressings are dry and intact. Left thigh dressing has a moderate amount of bloody drainage.

Monitor SaO2 every 2 hr is incorrect. The nurse should continuously monitor the child's SaO2 until it is stable. The child's SaO2 on arrival to the unit is below the expected reference range and is a concern that needs to be addressed. Provide 100% oxygen via face mask is correct. The nurse should provide 100% oxygen via face mask to the child because of their SaO2 and respiratory rate. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemental oxygen should be initiated. Check anterior neck and chest dressing for bleeding is correct. Upon return from the procedure, all surgical dressings should be assessed for drainage and to ensure the dressing is intact. Replace the dressing on the left thigh is incorrect. The nurse should not remove the dressing from the left thigh. Surgical dressings should not be removed from the donor site (left thigh) to avoid damage to the fragile epithelium. The dressing can be reinforced if necessary. Place a warm blanket on the child is correct. The child is exhibiting hypothermia. It is important for the child to have a stable body temperature because vasoconstriction can diminish blood flow to the surgical sites and impair healing. Keep the child's head in a neutral position is correct. The child's head should be kept in a neutral alignment to prevent hyperextension or hyperflexion and to prevent graft loss.