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ATI nursing care of children assessment

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Total Questions : 59

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Question 1:

1000:

Child is brought in by caregivers who report that child woke up 1 hr ago stating his "legs feel numb with muscle cramping." Caregivers report child had a mild upper respiratory infection 1 week ago and received influenza vaccine 5 days ago. Denies recent injuries.

Child is awake and alert, responds appropriately to questions. Heart rate regular, lungs clear bilaterally, and breathing is unlabored. Abdomen slightly firm, bowel sounds hypoactive. Reports last bowel movement was 3 days ago. Generalized muscle weakness noted in bilateral lower extremities. Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10. Patellar deep tendon reflexes 1+ bilaterally. No peripheral edema.

1400:

Admitted to pediatric unit.

1000:

  • Heart rate 100/min
  • Respiratory rate 24/min
  • Blood pressure 108/56 mm Hg
  • Oxygen saturation 99% on room air Temperature 36.7° C (98° F)

1200:

  • Heart rate 96/min
  • Respiratory rate 22/min, irregular
  • Blood pressure 106/56 mm Hg
  • Oxygen saturation 100% on room air
  • Temperature 36 6° C 197 9° F)

A nurse is caring for a 10-year-old male child.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body system

Findings

Neurological

 

Generalized muscle weakness noted in bilateral lower extremities.

Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10.

Patellar deep tendon reflexes 1+ bilaterally.

Child is awake and alert, responds appropriately to questions.

Gastrointestinal

Abdomen slightly firm, bowel sounds hypoactive.

Reports last bowel movement was 3 days ago.

Answer and Explanation

Explanation

Findings that require immediate follow-up:

  • Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
  • Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
  • Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.

Findings that do not require immediate follow-up:

  • Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
  • Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.

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Question 2:

A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Answer and Explanation

A
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Question 3:

A nurse is providing discharge teaching to the parent of a 5-year-old child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?

Answer and Explanation

A
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Question 4:

A nurse in an outpatient clinic is caring for a school-age child who has cystic fibrosis. Which of the following findings should the nurse monitor as the best indication of the child's nutritional status?

Answer and Explanation

A
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Question 5:

A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Answer and Explanation

A
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Question 6:

A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Answer and Explanation

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Question 7:

A nurse is assessing a child who has heart failure. Which of the following clinical manifestations should the nurse expect?

Answer and Explanation

A
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Question 8:

0900:

  • Temperature 38.8° C (101.8° F)
  • Heart rate 148/minute
  • Respiratory rate 66/minute
  • Blood pressure 80/44 mm Hg
  • Oxygen saturation 88% on room air

0900:

Infant presents with guardian who reports infant has an intermittent fever and runny nose that started 2 days ago. Guardian reports that the infant started coughing yesterday and the cough worsened overnight. Reports the infant has not breastfed as often well for the last 24 hr and has seems to have difficulty breathing when sucking feeding. Last wet diaper noted was 3 hr ago. Guardian states infant attends daycare and has been exposed to respiratory syncytial virus (RSV).

Anterior fontanel soft and flat, oral mucosa moist. Large amount of clear nasal drainage noted. Nasal flaring and intercostal retractions with decreased breath sounds in bases and bilateral scattered wheezes. Heart rate regular, capillary refill 2 seconds. Skin turgor elastic.

A nurse is caring for a 4-month-old infant.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the infant is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the infant's progress.

Answer and Explanation

Explanation

Condition Most Likely Experiencing: Bronchiolitis

The infant's symptoms—fever, cough, nasal congestion, wheezing, nasal flaring, intercostal retractions, and difficulty feeding—are characteristic of bronchiolitis, commonly caused by RSV in infants.

Actions to Take:

  • Administer Oxygen via nasal cannula: The infant's low oxygen saturation (88% on room air) and respiratory distress (nasal flaring, retractions) indicate the need for supplemental oxygen to ensure adequate oxygenation and reduce respiratory distress.
  • Suction nares with a bulb aspirator: Suctioning the infant’s nasal passages helps clear mucus and improve breathing. Infants with RSV often have significant nasal congestion that can impair feeding and breathing, so clearing the airways is crucial for respiratory management.

Parameters to Monitor:

  • Oxygen saturation via continuous pulse oximetry: Monitoring oxygen saturation provides critical information on the infant’s respiratory status and helps assess the effectiveness of oxygen therapy.
  • Respiratory effort and breath sounds: The infant is showing signs of increased respiratory effort (e.g., nasal flaring, intercostal retractions) and abnormal breath sounds (e.g., wheezes). Monitoring these parameters helps assess the severity of respiratory distress and guides further interventions.

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Question 9:

2000:

Infant awake and alert in parent's arms in bedside chair. Trunk, arms, and hands warm to palpation. Edema noted to hands, feet, and periorbital area. Weak bilateral femoral pulses. Lower extremities cool to palpation. Lungs clear bilaterally on auscultation. Mucous membranes pink and moist..

2200:

Infant asleep in crib. Heart rate regular, no murmur on auscultation.

2000:

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Temperature 37° C (98.6° F)

Oxygen saturation 97% on room air, right wrist

A nurse on a pediatric unit is caring for a 5-week-old infant.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

2000:

Infant awake and alert in parent's arms in bedside chair. Trunk, arms, and hands warm to palpation. Edema noted to hands, feet, and periorbital area. Weak bilateral femoral pulses. Lower extremities cool to palpation. Lungs clear bilaterally on auscultation. Mucous membranes pink and moist.

2200:

Infant asleep in crib. Heart rate regular, no murmur on auscultation.

Vital Signs

2000:

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Temperature 37° C (98.6° F)

Oxygen saturation 97% on room air, right wrist

Answer and Explanation

Explanation

Findings that require follow-up:

  1. Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
  2. Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
  3. Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
  4. Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.

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Question 10:

0130:

6-week-old infant brought in by parents for evaluation of poor feeding, fussiness, and new onset of fever. Parents report infant last breastfed for 5 min about 8 hr ago and has not been interested in feeding since. Has had 1 wet diaper and no stools in past 8 hr. Infant lethargic, whimpered during assessment. Skin hot and dry, mucous membranes dry. Anterior fontanel sunken. Heart rhythm regular. Lung sounds diminished in right lobes with occasional coarse crackles. Left lobes clear to auscultation. Moderate substernal and intercostal retractions noted. Abdomen soft with mild distention, active bowel sounds in all 4 quadrants. Weight 3855 grams (8 lb 8 oz). Weight 2 weeks ago was 4082 grams (9 lb) at well-child visit per parent's report.

0200:

Infant assessed by provider, prescriptions received. Infant asleep in parent's arms.

0130:

  • Temperature: 38.3° C (100.9° F)
  • Heart Rate: 180/min
  • Respirations: 60/min
  • Oxygen Saturation: 92% on room air

A nurse in an emergency department is caring for an infant.

Exhibits

The nurse on the pediatric unit is reviewing the infant's medical record immediately after receiving report from the emergency department nurse. Which of the following information requires immediate follow-up? Select all that apply.

Answer and Explanation

A
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