ATI PN nursing care of children 2020 with NGN II (2024)

Choice A reason:

Being adopted is not inherently a risk factor for physical maltreatment. It is essential to assess various factors in the child's environment and relationships.

Choice B reason:

Correct. Premature infants may face additional stressors and vulnerabilities, which can sometimes contribute to a higher risk of physical maltreatment. This is an important consideration in the assessment of suspected maltreatment.

Choice C reason:

Myopia (nearsightedness) is a visual impairment and is not directly associated with an increased risk of physical maltreatment.

Choice D reason:

Acute otitis media (ear infection) is a common childhood ailment and is not directly linked to an increased risk of physical maltreatment.

Choice A reason:

Roseola infantum is a common viral illness in infants and young children, but it is not considered a notifiable infectious disease.

Choice B reason:

Correct. Measles is a notifiable infectious disease. This means that healthcare providers are required to report any diagnosed cases to public health authorities due to its potential for outbreaks.

Choice C reason:

Fifth disease, caused by parvovirus B19, is typically a mild viral illness in children and is not classified as a notifiable infectious disease.

Choice D reason:

Scabies is a parasitic infestation, not an infectious disease. It is caused by the Sarcoptes scabiei mite and is not considered notifiable.

Choice A reason:

A subdural hematoma may not directly affect the fontanels. Depressed fontanels can be a sign of dehydration or other underlying conditions, but they are not specifically associated with a subdural hematoma.

Choice B reason:

A subdural hematoma would not typically cause a decrease in body temperature. This finding may be related to other factors, but it is not a characteristic sign of a subdural hematoma.

Choice C reason:

Correct. A subdural hematoma is a collection of blood between the dura mater and the brain. This can lead to increased intracranial pressure and result in the infant being difficult to arouse.

Choice D reason:

While a weak cry can be an indication of distress or illness in an infant, it is not a specific sign of a subdural hematoma. Other assessments, including neurological signs, are crucial in evaluating the infant's condition.

Choice A reason:

Hypersomnia (excessive sleepiness) is not a typical finding in Cushing's syndrome. Instead, children with Cushing's syndrome may experience insomnia or disrupted sleep patterns.

Choice B reason:

Hypotension (low blood pressure) is not a characteristic finding in Cushing's syndrome. Elevated blood pressure is more commonly associated with this condition.

Choice C reason:

Rapid weight loss is not a typical finding in Cushing's syndrome. Instead, children with Cushing's syndrome may experience weight gain, particularly in the face (moon face), abdomen, and upper back.

Choice D reason:

Correct. Rounded facial features, often referred to as "moon face," are a characteristic finding in children with Cushing's syndrome. This is due to the redistribution of fat in the body, particularly in the face and trunk.

Choice A reason:

Using four words in a sentence is an appropriate developmental milestone for a 3-year-old child. By this age, children typically have a vocabulary that allows them to form short sentences and express themselves.

Choice B reason:

Tying shoelaces is a fine motor skill that is typically developed later, around 5-6 years of age.

Choice C reason:

Skipping on alternate feet is a gross motor skill that is typically developed around 4-5 years of age.

Choice D reason:

Naming the days of the week is a cognitive skill that is typically developed later, around 5-6 years of age. It involves not only memory but also an understanding of the concept of days and their order.

Choice A reason:

Giving the infant a bottle immediately before bedtime can actually exacerbate gastroesophageal reflux, as lying down right after feeding can increase the likelihood of regurgitation.

Choice B reason:

Switching to a soy-based formula is not the first-line intervention for gastroesophageal reflux. Additionally, soy-based formulas are not recommended for all infants and should be used under specific circ*mstances.

Choice C reason:

This statement is correct. Keeping the infant at a 30° angle for 1 hour following each feeding can help reduce the likelihood of gastroesophageal reflux. This position helps gravity keep the stomach contents from flowing back up into the esophagus.

Choice D reason:

Limiting formula feedings to every 6 hours may not be appropriate for a 2-month-old infant, as they typically require more frequent feedings for proper growth and development.

Choice A reason:

Using a bleach-based solution to clean the bedside table is an appropriate measure to prevent the spread of Clostridium difficile bacteria, as bleach is effective in killing spores.

Choice B reason:

While hand sanitizer is useful for killing many types of bacteria and viruses, it may not be as effective against Clostridium difficile spores. Washing hands with soap and water is preferred.

Choice C reason:

Placing the toddler in a negative-airflow room is not necessary for managing Clostridium difficile diarrhea. Standard precautions and proper hygiene are sufficient.

Choice D reason:

Loperamide is not typically recommended for managing Clostridium difficile diarrhea, as it may worsen the condition by slowing down the bowel motility. The primary treatment is discontinuing the antibiotic that caused the infection and, in some cases, using specific antibiotics to target the C. difficile bacteria.

Choice A reason:

Providing detailed information about the procedure is important, but the first step in obtaining informed consent is to ensure that the parent understands the information. This can be achieved by assessing their understanding.

Choice B reason:

Discussing the benefits of the procedure is part of providing information for informed consent, but it should come after assessing the parent's understanding.

Choice C reason:

Explaining the risks associated with the procedure is important, but the first step is to ensure the parent comprehends this information, which can be achieved through assessment.

Choice D reason:

This statement is correct. Before proceeding with detailed information, it is essential to determine the parent's current understanding of the procedure to ensure they can make an informed decision.

Choice A reason:

Wrapping the extremity loosely with an elastic bandage may provide support but is not specifically aimed at reducing swelling.

Choice B reason:

Applying warm compresses can be beneficial for some types of injuries, but for a sprained wrist, cold compresses are more effective in reducing swelling.

Choice C reason:

This statement is correct. Elevating the extremity above the level of the heart helps to reduce swelling by promoting venous return and reducing blood flow to the affected area.

Choice D reason:

Encouraging active range of motion may be important for rehabilitation, but it is not the initial intervention for minimizing swelling in the first 12 to 24 hours after a sprain.