ATI Nursing Care of Children Assessment
2. A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following
... [Show More] manifestations should alert the nurse to a possible hemolytic transfusion reaction?
• Flank pain
3. 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
4. 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.”
5. 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
6. A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.)
• Ankle clonus
• Exaggerated stretch reflexes
• Contractures
7. A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
• Absence of peristalsis
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11. A nurse is assessing a 4 year old child at well-child visit. Which of the following developmental milestones should the nurse expect to observe?
• Cuts an outlined shape using scissors
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13. 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.
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17. A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
• Sodium 140 mEq/L
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24. 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
25. A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify 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.
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28. A nurse is assessing a 3-year-old toddler at a well-child visit. Which of following manifestations should the nurse report to the provider?
• Respiratory rate 45/min
29. A nurse is caring for an infant who has respiratory synctivial virus (RSV). Which of the following actions should the nurse implement for infection control?
• Have a designated stethoscope in the infant’s room.
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33. 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
34. A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
• Loud, harsh murmur
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36. A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?
• Perform a finger stick.
37. A nurse in an emergency department is caring for a schoolage child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
• Administer epinephrine IM to the child
38. A nurse is receiving change-of-shift report for four children. Which of the following should the nurse see first?
• A school-age who has sickle cell anemia and reports decreased vision in the left eye.
39. 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?
• Place the child in a side-lying position
40. A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?
• “I should keep my child indoors when I mow the yard.”
41. 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.”
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43. A nurse in an emergency department is caring for a schoolage child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
• Give morphine 0.05 mg/kg/IV
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47. A nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral?
• Speech therapist
48. 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
49. 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
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51. 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.”
52. A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
• Oral rehydration solution
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56. A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis.
Which of the following locations should the nurse identify as
McBurney’s point?
• A is correct: The nurse should identify this area of the client’s abdomen as McBurney’s ppoint. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client’s anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.
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58. 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.”
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ATI Nursing Care of Children Assessment 2019 B
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3. A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
• Increase fat content in the child’s diet to 40% of total calories
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5. A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
• Difficulty concentrating
6. A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?
• Nasal flaring
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11. A nurse in an emergency department is assessing a 3month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestation should the nurse identify as an indication that the infant has moderate to severe dehydration?
• Sunken anterior fontanel
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13. A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse take?
• “You should offer your child high-protein meals and snacks throughout the day.”
14. A nurse in an emergency department is caring for a schoolage child who has epiglottitis. Which of the following actions should the nurse take?
• Monitor the child’s oxygen saturation
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21. A nurse is planning care for a newly admitted school-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include?
• Ensure the oxygen source is functioning in the child’s room.
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23. A nurse is creating a plan of care for a preschooler who has Wilms’ tumor and is scheduled for surgery. Which of the following should the nurse include?
• Avoid palpating the abdomen when bathing the child before surgery. [Show Less]