ATI_RN Pediatric Nursing 2023 at at Baton Rouge Community College
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Free ATI_RN Pediatric Nursing 2023 at at Baton Rouge Community College Questions
A nurse is teaching a group of parents about body image during adolescence. Which of the following information should the nurse include?
- Adolescents tend to compare their sexual development to their peers.
- Adolescents typically begin to identify differences in skin color.
- Adolescents frequently express concerns about body image to their family.
- Adolescents consider their extremities the most important part of their body.
Explanation
During adolescence, rapid physical and sexual changes make body image a central developmental concern. Adolescents commonly compare their height, weight, body shape, and stage of sexual maturation with those of their peers to determine whether they are developing “normally.” These comparisons strongly influence self-esteem and confidence and can contribute to anxiety or dissatisfaction, especially if adolescents perceive themselves as developing earlier or later than others.
Correct Answer Is:
A. Adolescents tend to compare their sexual development to their peers.A nurse is teaching a parent of a 10-month-old infant about home safety. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- Remove labels from containers that contain toxic substances.
- Keep toilet lids in the upright position.
- Place gates at the top and bottom of the stairs.
- Ensure the crib mattress is in the lowest position.
- Select a toy chest that has a heavy, hinged lid.
Explanation
Explanation
C. Place gates at the top and bottom of the stairs.At 10 months of age, infants are highly mobile and often crawl, pull to stand, or cruise along furniture. They do not have the coordination or judgment to safely navigate stairs. Installing safety gates at both the top and bottom of stairways significantly reduces the risk of falls, which are a leading cause of serious injury in infants.
D. Ensure the crib mattress is in the lowest position.
As infants grow, they gain the ability to pull themselves into a standing position. Keeping the crib mattress at the lowest level prevents the infant from climbing or falling out of the crib. This intervention reduces the risk of head injury and other fall-related trauma and is an essential safety measure for this developmental stage.
Correct Answer Is:
C. Place gates at the top and bottom of the stairs.D. Ensure the crib mattress is in the lowest position.
A nurse is conducting a health history of an adolescent who is accompanied by a parent. Which of the following interviewing techniques should the nurse use?
- Provide an opinion when discussing the adolescent’s sexual history.
- Use open-ended questions when asking the adolescent about their health history.
- Communicate sympathy when asking the adolescent about their chief complaint.
- Interview the parent first when collecting the adolescent’s health history.
Explanation
Explanation
Using open-ended questions encourages adolescents to share information freely and honestly without feeling judged or pressured. This approach helps build trust, supports therapeutic communication, and allows the nurse to obtain more complete and accurate information about the adolescent’s physical, emotional, and social health. Open-ended questions are especially important for adolescents, who may be hesitant to discuss sensitive topics unless they feel respected and heard.Correct Answer Is:
B. Use open-ended questions when asking the adolescent about their health history.Why the other options are incorrect:
A nurse is assessing a school-age child who is receiving prednisolone. For which of the following adverse effects should the nurse monitor?
- Decreased bone density
- Decreased intraocular pressure
- Weight loss
- Hypoglycemia
Explanation
Prednisolone is a corticosteroid, and long-term or repeated use in children can interfere with bone growth and calcium metabolism. Corticosteroids decrease bone formation and increase bone resorption, placing pediatric clients at risk for decreased bone density and fractures. Because children are still growing, monitoring for bone-related adverse effects is especially important to prevent long-term skeletal complications.
Correct Answer Is:
A. Decreased bone densityA nurse is providing discharge teaching to the guardian of an infant who had a large myelomeningocele repair in the lumbar area. Which of the following instructions should the nurse include?
- Clean intermittent catheterization every 8 hr.
- Check toys and pacifiers for the presence of latex.
- Anticipate gradual loss of function in the lower extremities.
- Use a rectal thermometer to stimulate the passage of stool twice per day.
Explanation
Infants with myelomeningocele are at high risk for developing a latex allergy due to frequent exposure to latex-containing medical supplies during surgeries and ongoing care. Even nonmedical items such as toys, pacifiers, and bottle nipples can contain latex and trigger severe allergic reactions. Educating caregivers to identify and avoid latex-containing products is essential to prevent hypersensitivity reactions, including anaphylaxis, and is a critical component of long-term home care for these infants.
Correct Answer Is:
B. Check toys and pacifiers for the presence of latex.A nurse is assessing an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?
- Lanugo
- Hypertension
- Tachycardia
- Fever
Explanation
Anorexia nervosa is associated with severe weight loss and loss of subcutaneous fat, which impairs the body’s ability to regulate temperature. As a compensatory mechanism, the body grows fine, soft hair called lanugo to help conserve heat. Lanugo is a classic physical finding in adolescents with anorexia nervosa and reflects chronic malnutrition and prolonged energy deficiency rather than an acute illness or infection.
Correct Answer Is:
A. LanugoA nurse is teaching the mother of an 8-week-old infant who is breastfed about methods to manage colic. Which of the following instructions should the nurse recommend? (Select all that apply.)
- Apply a hot water bottle to the infant’s abdomen.
- Feed the infant 1/2 tsp of honey daily.
- Offer the infant 1 oz of star anise tea.
- Have the mother avoid milk products.
- Allow the infant to suck on a pacifier.
Explanation
Explanation
D. Have the mother avoid milk products.In breastfed infants, colic can be associated with sensitivity to proteins in the mother’s diet, particularly cow’s milk. Eliminating dairy products may reduce gastrointestinal irritation and excessive crying. Dietary modification in the breastfeeding parent is a recommended, noninvasive strategy to help manage colic symptoms in young infants.
E. Allow the infant to suck on a pacifier.
Non-nutritive sucking is a soothing technique that can help calm infants with colic. Sucking promotes self-soothing, reduces crying episodes, and provides comfort without introducing additional feeding or substances. Pacifier use is considered a safe and effective method to help manage colic-related irritability in young infants.
Correct Answer Is:
D. Have the mother avoid milk products.E. Allow the infant to suck on a pacifier.
A nurse is caring for a child who has bacterial meningitis. Which of the following findings should indicate to the nurse that the child can be removed from droplet precautions?
- Antibiotics initiated 24 hr ago
- Negative cerebrospinal fluid culture
- Temperature below 37.4° C (99.3° F)
- Absent nuchal rigidity
Explanation
Explanation
Children with bacterial meningitis require droplet precautions to prevent transmission of infectious organisms, particularly during the early phase of illness. According to infection-control guidelines, droplet precautions may be discontinued after the child has received effective antibiotic therapy for at least 24 hours, as this significantly reduces the risk of transmission. Clinical improvement or laboratory results are not required before removing precautions; timing of appropriate antibiotic treatment is the key determinant.Correct Answer Is:
A. Antibiotics initiated 24 hr agoWhy the other options are incorrect:
A nurse is admitting an 8-year-old child to the pediatric unit.
Nurses' Notes
Day 1, 1020:
Child is a direct admit from a pediatric clinic and is accompanied by their guardian. Guardian reports that child has been sick for about 2 days with fever and chills and appears to be more irritable. Approximately 2 weeks ago, guardian reports that their child had an upper respiratory infection that was managed with over-the-counter medications. Guardian also reports that child has no prior medical conditions and has received all recommended scheduled immunizations.
1030:
Child reports nausea and headache and rates the pain as 7 on a scale of 0 to 10. Lethargic and responsive to verbal stimuli. Agitation and irritability noted. Nuchal rigidity noted. Pupils equal, round, and reactive to light. Mucous membranes pink dry, and sticky. Cervical lymph slightly enlarged. Respirations irregular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial and pedal pulses 1+ bilateral. Capillary refill seconds. Abdomen flat and non-distended. Bowel sounds ac in all 4 quadrants. Extremities are warm and dry to touch
Flow Sheet
Day 1, 1030:
Temperature 38.7° C (101.7° F)
Heart rate 114/min
Respiratory rate 26/min
Blood pressure 114/80 mm Hg
SpO2 97% on room air
Height 122 cm (48 in)
Weight 29 kg (64 lb)
Diagnostic Results
Day 1, 1040:
Potassium 3.8 mEq/L (3.4 to 4.7 mEq/L)
Hemoglobin 9.5 g/dL (10 to 15.5 g/dL)
Hematocrit 30% (32% to 44%)
RBC count 4.2 x 106/pL (4.0 to 5.5 x 106/pL)
WBC count 14,000 mm3 (5,000 to 10,000 mm3)
Platelets 350,000/mm3 (150,000 to 400,000/mm3)
Glucose 90 mg/dL (< 200 mg/dL)
Blood cultures pending
Provider Prescriptions
Day 1, 1020:
Admit directly to pediatric unit.
Keep child NPO.
Obtain comprehensive metabolic panel and blood cultures
STAT.
Vital signs every 30 min, then every hr x 4, then every 4 hr.
Exhibit 1
Nurses' Notes
Day 1, 1020:
Child is a direct admit from a pediatric clinic and is accompanied by their guardian. Guardian reports that child has been sick for about 2 days with fever and chills and appears to be more irritable. Approximately 2 weeks ago, guardian reports that their child had an upper respiratory infection that was managed with over-the-counter medications. Guardian also reports that child has no prior medical conditions and has received all recommended scheduled immunizations.
1030:
Child reports nausea and headache and rates the pain as 7 on a scale of 0 to 10. Lethargic and responsive to verbal stimuli. Agitation and irritability noted. Nuchal rigidity noted. Pupils equal, round, and reactive to light. Mucous membranes pink dry, and sticky. Cervical lymph slightly enlarged. Respirations irregular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial and pedal pulses 1+ bilateral. Capillary refill seconds. Abdomen flat and non-distended. Bowel sounds ac in all 4 quadrants. Extremities are warm and dry to touch
Exhibit 2
Flow Sheet
Day 1, 1030:
Temperature 38.7° C (101.7° F)
Heart rate 114/min
Respiratory rate 26/min
Blood pressure 114/80 mm Hg
SpO2 97% on room air
Height 122 cm (48 in)
Weight 29 kg (64 lb)
Exhibit 3
Diagnostic Results
Day 1, 1040:
Potassium 3.8 mEq/L (3.4 to 4.7 mEq/L)
Hemoglobin 9.5 g/dL (10 to 15.5 g/dL)
Hematocrit 30% (32% to 44%)
RBC count 4.2 x 106/pL (4.0 to 5.5 x 106/pL)
WBC count 14,000 mm3 (5,000 to 10,000 mm3)
Platelets 350,000/mm3 (150,000 to 400,000/mm3)
Glucose 90 mg/dL (< 200 mg/dL)
Blood cultures pending
Exhibit 4
Provider Prescriptions
Day 1, 1020:
Admit directly to pediatric unit.
Keep child NPO.
Obtain comprehensive metabolic panel and blood cultures
STAT.
Vital signs every 30 min, then every hr x 4, then every 4 hr.
A nurse is reviewing the child's electronic medical record (EMR). Which of the following findings should the nurse identify as requiring immediate follow-up?
Select the 5 findings that require immediate follow-up.
- Hemoglobin
- Glucose
- Pain assessment
- Peripheral pulses
- Temperature
- Abdominal assessment
- Neurologic assessment
- WBC
Explanation
Explanation
C. Pain assessmentThe child reports a headache rated 7/10 accompanied by nausea, lethargy, and irritability. Severe headache in combination with nuchal rigidity and altered responsiveness is concerning for meningeal irritation or increased intracranial pressure. This finding requires immediate follow-up to guide urgent neurologic evaluation and intervention.
D. Peripheral pulses
Radial and pedal pulses documented as 1+ bilaterally indicate decreased peripheral perfusion. In the setting of fever, lethargy, and suspected infection, weak pulses may signal early circulatory compromise or sepsis. This finding requires prompt reassessment and close monitoring.
E. Temperature
A temperature of 38.7° C (101.7° F) with chills and irritability suggests an acute infectious process. Fever combined with neurologic signs raises concern for meningitis or systemic infection, requiring immediate follow-up for rapid evaluation and treatment.
G. Neurologic assessment
Lethargy, agitation, irritability, nuchal rigidity, and irregular respirations are significant neurologic red flags. These findings strongly suggest central nervous system involvement, such as meningitis or rising intracranial pressure, and require immediate provider notification and intervention.
H. WBC
An elevated WBC count of 14,000/mm³ indicates an active inflammatory or infectious process. When paired with fever and neurologic symptoms, this finding supports possible serious bacterial infection and requires urgent follow-up to prevent rapid deterioration.
Correct Answer Is:
C. Pain assessmentD. Peripheral pulses
E. Temperature
G. Neurologic assessment
H. WBC
A nurse is performing a home health visit for a pediatric client who has had a recent onset of headaches. The nurse notices the home is poorly ventilated, and there is no placement of carbon monoxide detectors. Which of the following appliances should the nurse identify as a potential source of carbon monoxide?
- Kerosene heater
- Electric stove
- Refrigerator
- Washing machine
Explanation
Explanation
Kerosene heaters are combustion-based appliances that burn fuel to produce heat. When used in poorly ventilated areas, they can release carbon monoxide, a colorless and odorless gas that interferes with oxygen delivery in the body. Children are especially vulnerable to carbon monoxide exposure, which commonly presents with headaches, dizziness, nausea, and lethargy. Identifying and addressing this source is critical to preventing carbon monoxide poisoning.Correct Answer Is:
A. Kerosene heaterWhy the other options are incorrect:
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