ATI Success Plan Missed Questions Week 4

A (The nurse should expect a 4-year-old child to have the fine motor ability to fasten buttons on a shirt; however, the child may have difficulty if the buttons are small)

A nurse is assessing a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. fastening buttons on a shirt B. tying shoelaces C. partying and combing hair D. cutting the meat at dinner

D (adolescents may spend time using a computer, but parents should know what they are doing and who they are communicating with and limit the time. The American Academy of Pediatrics guidelines recommends 2 hours of screen time daily)

A nurse is teaching a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? A. my child has frequent mood swings. B. my child ahs a very messy bedroom C. my child takes 1-2 showers per day D. my child spends 4 hours per day using online chat rooms

D (dry mucous membranes are an expected finding of moderate dehydration)

A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. absent tears B. weight loss >10% C. lethargy D. dry mucous membranes

C (The nurse should encourage this adolescent with idiopathic arthritis to attend school. The adolescent should attend school even on days when joint pain or stiffness occurs)

A nurse is providing teaching to an adolescent client who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? A. apply cold compresses to relieve your joint pain B. take opioids routinely C. attend school regularly D. adhere to an arthritis diet

C (the nurse should identify that vomiting, especially when unrelated to feedings, is a manifestation of digoxin toxicity. The nurse should report this finding to the provider immediately.)

A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? A. irritability B. diaphoresis C. vomiting D. tachycardia

B (Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair)

A nurse is an acute pediatric unit is caring for a 2 year old child who has separation anxiety when her parents to leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. the child tries to bite the nurse B. the child is withdrawn and refuses to talk C. the child attempts to run away to find her parents D. the child scream and cries loudly

D (an infant is expected to have the ability to sit up unsupported around 8 month of age. Therefore, the nurse should report this finding to the provider)

A nurse is assessing a 10 month old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider? A. the infant is unable to walk independently B. the infant's moro reflex is absent C. the infant's anterior fontanel is open D. the infant needs assistance to sit up

B (the nurse should identify that a heart rate of 110/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia)

A nurse is assessing a 6 year old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. dullness with chest percussion B. heart rate 110/min C. conjunctival discharge D. respiratory rate 28/min

C (when using the urgent versus nonurgent approach to client care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottis, a medical emergency. Left untreated, the child can develop a complete respiratory obstruction.)

A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. the child's temp is 39 C (102F) B. the child's skin is sallow C. the child is drooling D. the child's voice is hoarse

C (the nurse should identify that thin, frail extremities are related to malnourishment and can indicate child maltreatment. The nurse should investigate this finding further and report the results to the provider)

A nurse is assessing a school age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A bruising of the right elbow B dislocated left shoulder revealed by X-ray C thin, frail extremities D abrasions on both wrists

D (immediately following an injury, a joint should be rested, elevated and have ice applied to minimize bleeding into the joint)

A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0-10. Which of the following actions should the nurse take? A. administer an NSAID B. perform passive ROM exercises on the joint C. administer cryoprecipitate D. apply an ice pack to the joint

A (The nurse should identify that a hyper cyanotic spell occurs when a vascular spasm reduces pulmonary blood flow and forces blood to shunt from the right ventricle to the left ventricle through the ventricular septal defect. The nurse should place the infant in a knee-chest position to increase systemic vascular resistance, which will help force more blood through the pulmonary artery)

A nurse is caring for a 4 month old infant who has tetralogy of Fallot and experiences a hyper cyanotic spell. Which of the following actions should the nurse take? A. place the infant in knee-chest position B. begin cpr C. prepare to intubate the infant D. administer IV adenosine

C (the pressure created by a barium enema might force the bowel to resume a normal configuration. Some children with intussusception are treated with the barium enema and do not require surgical intervention)

A nurse is caring for a 6 month old infant who has intussusception. Which of the following actions should the nurse take? A. prepare to administer high-dose steroids B. give the child magnesium hydroxide PO C. prepare the child for a barium enema D. inform the parents that the child will need a colostomy

D (The nurse should offer chapter books as an appropriate diversional activity for a school-age child who has limited movement due to skeletal traction)

A nurse is caring for a 7 year old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. puzzle with large pieces B. building blocks C. finger paints D. chapter books

B (maintaining a semi-fowler's position promotes adequate ventilation. Flexing the knees slightly will likely be the most comfortable position for the child. Additionally, this promotes drainage of the cecum downward into the pelvis instead of upward toward the lungs)

A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain? A. supine B. semi-fowler's C. sims D. orthopneic

A (an infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation)

A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. transposition of the great arteries B. ventricular septal defect C. coarctation of the aorta d. patent ductus arteriosus

B (increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements)

A nurse is caring fora n infant who is postop following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A. measure the infant's intake and output B. measure the infant's head circumference C. check the infant's lower-extremity function D. monitor the infant's blood pressure

B ( the parent should encourage the child to remain physically active because this promotes lung expansion and air exchange)

A nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching? A. my child should not receive live virus vaccines B. i will encourage my child to participate in sports C. I will give the child aspirin when she has a fever D. My child will outgrow asthma by adulthood

D (zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping.)

A nurse is providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? A. dry the affected area with a hair dryer on the low setting twice per day B. use cloth diapers washed in a low-residue detergent C. wash the genital area vigorously with each diaper change D. leave the zinc oxide ointment intact and reapply as necessary during diaper changes

A (The nurse should explain that copying a circle is a skill achieved by the age of 4 years)

A nurse is providing teaching to the parents of a 4 year old child about fine motor development. Which of the following tasks should the nurse include as an expected finding for this age group? A. copying a circle B. cutting foods using a table knife C. beginning to write in cursive D. printing the first and last name clearly

D (the nurse should identify passive smoking as a risk factor for otitis media. Exposure to secondhand smoke promotes the attachment of pathogens to the middle ear, extends the inflammatory response, and impairs drainage through the eustachian tube. Each of these effects increases the risk for development of otitis media)

A nurse is teaching a group of parents and guardians about otitis media. Which of the following should the nurse identify as a risk factor for this illness? A. summer months B. breastfeeding C. ages 7-10 D. passive smoking

D (The nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo. When using the nonpharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. The technique can also be combined with relaxation and breathing techniques)

A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. give the child a kaleidoscope and ask the child to find different designs B. encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. encourage the child to focus on a recent pleasurable experience

A,C,D (The nurse should instruct the adolescent to increase intake of allowable foods when level of activity is increased. Exercise lowers blood glucose levels during & after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system & prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10-15 g/hour of moderate play/ activity. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids. The adolescent should continue with usual intake at mealtimes & follow the recommended meal plan as much as possible. Finally, the nurse should instruct the adolescent to eat a recommended snack 30 min prior to a planned activity such as playing baseball. If the game is prolonged, a snack should be consumed e

A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? A. I should eat extra food on busy days when I am more active B. I should wait for 2 hr after eating before going swimming with my friends C. I should increase my intake of sugar free-fluids when I am sick. D. I should eat a snack 30 min before my baseball games start. E. I should have a 16 oz sports drink if I start feeling weak or shaky.

A (An 18 month old toddler should be able to remove his or her own shoes, socks and gloves. The nurse should report this finding to the provider)

A nurse is assessing an 18-month old toddler during an exam. Which of the following findings should the nurse report to the provider? A. the toddler is unable to remove his shoes B. the toddler is unable to draw a plus sign C. the toddler is unable to jump off a step D. the toddler is unable to turn 1 page of a book at a time

A, B, E (Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on teaching the child's parents about topical application of an antibacterial ointment. The parents should wash their hands before and after contact with the affected area and wash the child's bed linens daily in hot water to decrease the risk of reinfection or transmission)

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness? select all that apply A. apply a topical antibacterial ointment to the lesions B. wash the child's linens daily with hot water C. administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. wash hands before and after contact with the affected area.