Nursing Care of Children Final ATI

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A two-month-old infant who has gastroesophageal reflux is thriving without other complications. Which instruction should the nurse include in the teaching plan?

  • A. Place the infant in the Trendelenburg position after feeding
  • B. Thicken formula with rice cereal
  • C. Give continuous nasogastric feedings
  • D. Give larger, less frequent feeds
Correct Answer: B

Rationale: The correct instruction for a two-month-old infant with gastroesophageal reflux who is thriving without complications is to thicken the formula with rice cereal. This can help reduce reflux by increasing the weight of the formula, making it less likely to be regurgitated. Placing the infant in the Trendelenburg position after feeding (Choice A) is not recommended as it can increase the risk of aspiration. Continuous nasogastric feedings (Choice C) are not typically indicated for uncomplicated reflux in infants. Giving larger, less frequent feeds (Choice D) can worsen reflux symptoms by overloading the stomach.

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An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions?

  • A. Justice
  • B. Autonomy
  • C. Beneficence
  • D. Nonmaleficence
Correct Answer: B

Rationale: Supporting an adolescent in making decisions about their care reflects the moral value of autonomy, emphasizing the importance of respecting the patient's right to make informed choices.

The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?

  • A. Send the child to his or her room if the child has one.
  • B. A general rule for length of time is 1 hour per year of age.
  • C. Select an area that is safe and nonstimulating, such as a hallway.
  • D. If the child cries, refuses, or is more disruptive, try another approach.
Correct Answer: C

Rationale: Time-outs should be in a safe, nonstimulating area, with the length typically being 1 minute per year of the child's age, not 1 hour.

Which distraction technique should be used for an adolescent child during a painful procedure?

  • A. Blowing bubbles
  • B. Guided imagery
  • C. EMLA cream
  • D. Sucrose solution
Correct Answer: B

Rationale: The correct answer is B: Guided imagery. Guided imagery is an effective distraction technique for adolescents as it helps them focus on positive mental images instead of the pain. This technique can be a powerful tool in managing pain and anxiety during procedures. Blowing bubbles (choice A) may be more suitable for younger children as it can engage them visually and help distract them. EMLA cream (choice C) is a topical anesthetic and not a distraction technique. Sucrose solution (choice D) is used for pain relief in infants, not typically for adolescents undergoing painful procedures.

The nurse is aware that which age group is at risk for childhood injury because of the cognitive characteristic of magical and egocentric thinking?

  • A. Preschool
  • B. Young school age
  • C. Middle school age
  • D. Adolescent
Correct Answer: A

Rationale: Preschool children are at higher risk for injury due to magical and egocentric thinking, which can lead to misjudgments about their abilities and dangers.

The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?

  • A. Respiratory rate of 20 breaths per minute
  • B. Heart rate of 89 beats per minute
  • C. Heart rate of 120 beats per minute
  • D. Respiratory rate of 24 breaths per minute
Correct Answer: C

Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.

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