ATI 2

For each assessment finding, click to specify if the finding is consistent with nightmares, sleep terrors, or insomnia. Each finding may support more than 1 disease process. 1. cow's milk 2. wheat bread 3. corn syrup 4. eggs

1

A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? 1. bulging anterior fontanel 2. bradycardia 3. tachypnea 4. polyuria

3

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following action should the nurse take? 1. apply cool compresses to the painful area 2. initiate contact isolation precautions 3. give the child flavored popsicles 4. administer phytonadione

3

A nurse is teaching a school-age child who has a new diagnosis of type 1 DM. Which of the following statements should the nurse make? 1. "If you take too much insulin, drink a sugar-free cola." 2. "You will need to decrease your insulin dosage when you become a teenager." 3. "You can use a vial of insulin for up to 30 days." 4. "Stop taking your insulin if you are vomiting."

3

A nurse is assessing a toddler who has measles. Which of the following findings should the nurse expect? 1. koplik spots 2. parotitis 3. strawberry tongue 4. paroxysmal cough

1

A nurse is caring for a preschool-age child who is dying. which of the following findings is an age-appropriate reaction to death by the child? SATA 1. The child views death as similar to sleep. 2. The child is interested in what happens to his body after death. 3. The child recognizes that death is permanent. 4. The child believes his thoughts can cause death. 5. The child thinks death is a punishment.

1 4 5

A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation? a. the child prefers playmates of the same sex b. the child is competitive when playing board games c. the child complains daily about going to school d. the child enjoys spending time alone

c

For each assessment finding, click to specify if the finding is consistent with nightmares, sleep terrors, or insomnia. Each finding may support more than 1 disease process. a. Wash and dry the infant's genitalia and perineum thoroughly. b. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area. c. Avoid placing the scrotum inside the collection bag. d. Wait several hours after positioning the device before checking it.

A

A nurse in an ED is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? 1. Excessively prolonged expiration 2. Increased diaphoresis 3. Increased production of frothy sputum 4. Sudden decrease in wheezing

4

A nurse is an ED is caring for an 8 year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? 1. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine 2. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) 3. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine 4. Adult tetanus booster (Td)

4

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following lab values should the nurse expect? 1. Platelet count 120,000/mm3 2. Serum sodium 160 mEq/L 3. Hgb 9 g/dL 4. Serum cholesterol 700 mg/dL

4

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? 1. Perform passive range of motion for unaffected joints. 2. Apply a pressure-reducing overlay to the child's mattress. 3.Increase the child's fluid intake. 4. Encourage the child to use an incentive spirometer.

4

A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? 1. Ask the child to hold his breath and then blow it out slowly. 2. Ask the child to describe a pleasurable event. 3. Bounce the child gently while holding him upright. 4. Rock the child in long rhythmic movements.

4

A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? 1. restrict the child's potassium intake 2. administer acetaminophen to the child twice daily 3. weight the child once a each week 4. keep the child away from people who have an infection

4

A nurse is teaching a school-age who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? 1. "I will give you an antibiotic before your procedure." 2. "I will place you on your side during the procedure." 3. "You might have a headache following the procedure." 4. "I will place a pressure dressing over the area following the procedure."

4

A nurse is teaching the parent of a 12 month old infant about nutrition. which of the following statements by the parent indicates a need for further teaching? 1. "I can give my baby 4 ounces of juice to drink each day." 2. "I will offer my baby dry cereal and chilled banana slices as snacks." 3. "I am introducing my baby to the same foods the family eats." 4. "My infant drinks at least 2 quarts of skim milk each day."

4

A nurse at a clinic is preparing to administer immunizations to a 5 year old child. Which of the following immunizations should the nurse plan to give? a. DTaP b. PCV c. HiB d. Hep B

A

A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter. Which of the following statements should the nurse include when teaching the child's parent? 1. "The PICC line will last several weeks with proper care." 2. "The public health nurse will rotate the insertion site every 3 days." 3. "You will need to make certain the arm board is in place at all times." 4. "Your child will go to the operating room to have the line placed."

1

A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? 1. Encourage the parents to bring in the child's stuffed animal. 2. Give the child choices when planning daily activities. 3. Administer phenytoin three times per day. 4. Provide a shared room with another child his age.

1

A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? 1. Schedule the child for a preoperative visit to the facility. 2. Inform the child he will be put to sleep during the procedure. 3. Read the child a story about a cartoon character having a similar operation. 4. Tell the child the appointment is to have his throat checked.

1

A nurse is providing teaching to the parent of a 2 year old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? 1. "My child should consume 1,000 calories per day." 2. "My child should have 4 ounces of protein per day." 3. "I should give my child 32 ounces (4 cups) of milk per day." 4. "I should feed my child 4 ounces (1/2 cup) of vegetables per day."

1

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the lab values? 1. "The infant might be dehydrated." 2. "The infant might be anemic." 3. "The infant might have received too much fluid." 4. "The infant might have leukemia."

1

A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? 1. "I will give my child a dose of albendazole today and again in 2 weeks." 2. "I will collect specimens immediately after my child has a bowel movement." 3. "I will give my child a tub bath twice each day." 4. "I will place my child's bed linens in a sealed plastic bag for 7 days."

1

A nurse is teaching the patient of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? 1. "My child may take aspirin for his joint pain." 2. "My child will need a blood transfusion prior to discharge." 3. "I will need to wear a gown when in my child's room." 4. "I will apply lotion to my child's peeling hands."

1

A school nurse is assessing an adolescent child who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? 1. potential for sustaining abdominal trauna 2. deficient dietary intake 3. exposing peers to the illness 4. straining sore joints

1

A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? 1. Platelet count 500,000 mm3 2. RBC 2.5 million/uL 3. WBC 4,000/mm3 4. Hct 60%

2

A nurse is caring for a 10-year-old child who shoule reduce his fat intake. Which of the following menu choices should the nurse suggest? 1. A hot dog on a whole wheat bun 2. 3 oz of baked chicken on a whole wheat roll 3. 1/2 cup diced potatoes with scrambled eggs 4. A medium blueberry muffin

2

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? 1. maintain the child on strict bed rest 2. check the child's blood pressure every 4hr 3. administer albumin to the child every 8hr 4. provide the child with a low-carb diet

2

For each assessment finding, click to specify if the finding is consistent with nightmares, sleep terrors, or insomnia. Each finding may support more than 1 disease process. 1. pneumococcal polysaccharide 2. meningococcal polysaccharide 3. rotavirus 4. herpes zoster

2

A nurse is assessing a child who has a VSD. Which of the following findings should the nurse expect? 1. diastolic murmur 2. murmur at the left sternal border 3. cyanosis that increases with crying 4. widened pulse pressure

2 4번은 PDA

A school nurse is assessing who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? SATA 1. bradycardia 2. nausea 3. hypertension 4. urticaria 5. stridor

2 4 5

A nurse in the ED is caring for 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? 1. "The absence of oral burns excludes the possibility of esophageal burns." 2. "Treatment focuses on neutralization of the chemical." 3. "Injury by a corrosive liquid is more extensive than by a corrosive solid." 4. "Immediate administration of activated charcoal is warranted."

3

A nurse is providing education to the parent of a toddler who is about to receive an MMR immunization. Which of the following statements by the parent indicates an understanding of the teaching? 1. "My child should not play with other children for 2 days." 2."I will need to return in 2 weeks for my child to receive the varicella immunization." 3."I will help my child to blow bubbles during the injection." 4. "My child may have some drainage from the injection site."

3

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? 1. temp 37.5 2. apical pulse rate 140/min 3. BP 86/40 mm Hg 4. RR 32/min

3 hypotension