Nursing Care of Children ATI

Nursing Care of Children ATI Related

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The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?

  • A. Repression
  • B. Regression
  • C. Rationalization
  • D. Fantasy
Correct Answer: B

Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.

You may also like to solve these questions

At which age can most infants sit steadily unsupported?

  • A. 4 months
  • B. 6 months
  • C. 8 months
  • D. 12 months
Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

What approach is the most appropriate when performing a physical assessment on a toddler?

  • A. Demonstrate the use of equipment
  • B. Perform traumatic procedures last
  • C. Use minimum physical contact initially
  • D. Always proceed systematically in a head-to-toe direction
Correct Answer: C

Rationale: The most appropriate approach when performing a physical assessment on a toddler is to use minimum physical contact initially. This helps gain the toddler's cooperation and reduces their distress. Performing traumatic procedures last is crucial as they are likely to upset the child and should be handled with care. Demonstrating the use of equipment may be complex for toddlers to understand, so it is not the most appropriate initial approach. Proceeding systematically in a head-to-toe direction is a good practice but using minimum physical contact initially is more important to establish trust and cooperation with the toddler.

The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant's mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?

  • A. Recommend supplemental feedings of formula.
  • B. Explain that this weight loss is within normal limits.
  • C. Assess the child further to determine the cause of excessive weight loss.
  • D. Encourage the mother to express breast milk for bottle-feeding the infant.
Correct Answer: B

Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.

The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?

  • A. I will use precautions when I give an infant oral care
  • B. I will use precautions when I change an infant's diaper
  • C. I will use precautions when I come in contact with blood and body fluids
  • D. I will use precautions when administering oral medications to a school-age child
Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?

  • A. Monitor blood pressure every 30 minutes.
  • B. Reposition the child every two hours.
  • C. Limit visitors.
  • D. Encourage fluids.
Correct Answer: B

Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.

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