ATI RN NURSING CARE OF CHILDREN PROCTORED EXAM
1. A nurse is caring for a child who has absence seizures. Which
of the following findings should the
... [Show More] nurse expect? (Select all
that apply.) A. Loss of consciousness
B. Appearance of daydreaming
C. Dropping held objects
D. Falling to the floor
E. E. Having a piercing cry
55a
1. A. CORRECT: Loss of consciousness for 5 to 10 seconds is a manifestation of an absence
seizure.
B. CORRECT: Behavior that resembles daydreaming is a manifestation of an
absence seizure.
C. CORRECT: A child who is having absence seizures might drop a held object.
D. Falling to the floor is a manifestation of a tonic-clonicseizure.
E. A piercing cry is a manifestation of a tonic-clonicseizure.
55b
2. A nurse is caring for a child who just experienced a
generalized seizure. Which of the following is the priority action
for the nurse to take?
A. Maintain the child in a side-lying position.
B. Loosen the child's restrictive clothing.
C. Reorient the child to the environment.
D. Note the time and characteristics of the
child's seizure. 56a
2. A. CORRECT: Following a seizure, children often experience vomiting. Using the
airway, breathing, circulation priority-setting framework, the first action the nurse
should take is to place the child in a side-lying position to maintain a patent airway and
prevent aspiration of secretions. B. Loosening the child's restrictive clothing is an
appropriate action. However, it is not the priority action.
C. R eorienting the child to the environment following a generalized seizure is an
appropriate action. However, it is not the priority action. D. Noting the time and
characteristics of the child's seizure is an appropriate action. However, it is not the
priority action.
56b
3. A nurse is providing teaching to the parent of a child
who is to have an electroencephalogram (EEG). Which
of the following responses should the nurse include in
the teaching?
A. "Decaffeinated beverages should be offered on the
morning of the procedure.
" B. "Do not wash your child's hair the night before the
procedure."
C. "Withhold all foods the morning of the
procedure."
D. "Give your child an analgesic the night before
the procedure."
57a
3. A. CORRECT: Caffeine can alter the results of an
EEG and should be avoided prior to the test.
B. The child's hair should be washed to remove oils that permit adherence
of the EEG electrodes.
C. Foods are not withheld prior to an EEG.
D. Analgesics can alter the results of an EEG and should be avoided prior to
the test.
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?
a. Laryngeal edema
b. Flank pain
c. Distended neck veins
d. Muscular weakness
Answer- b. 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- Laryngeal edema is an indication of an allergic reaction to the blood transfusion.
C- Distended neck veins are an indication of circulatory overload, which is a complication of
a blood transfusion.
D- Muscle weakness is an indication of an electrolyte disturbance, which is a complication of
a blood transfusion.
A community health nurse is assessing an 18-month-old toddler in a community day care.
Which of the following findings should the nurse identify as a potential indication of
physical neglect?
a. Resists having an axillary temperature taken
b. Exhibits withdrawal behaviors when her parent leaves
c. Has multiple bruises on her knees
d. Poor personal hygiene
Answer- d. Poor personal hygiene. Poor personal hygiene in a toddler is a potential
indication of physical neglect. Because toddlers are still dependent on their parents for help
with hygiene needs, poor personal hygiene indicates a lack of supervision.
A- The toddler has begun to develop a sense of body image and boundaries and can be
resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary
temperature. Therefore, this finding is not an indication of physical neglect [Show Less]