Question

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

Answer 1

Correct Answers:

Stabilize the infant's spine.
Palpate fontanel level.
Assess pupillary reaction to light.
Measure the infant's head circumference.

Rationale :

🛑Stabilizing the infant’s spine is crucial after a fall involving stairs, especially with a head injury, due to the risk of cervical spine trauma.

🧠Palpating the fontanel can provide important information regarding intracranial pressure, especially in infants with subdural hematoma.

🔦Assessing pupil reaction evaluates for neurological deterioration and helps monitor for signs of increased intracranial pressure.

📏Measuring head circumference helps identify progressive swelling or hematoma expansion, which is essential in monitoring infants with head trauma.

🍽️Feeding should not be encouraged when the infant is hard to arouse; this may indicate neurological compromise, and feeding could pose an aspiration risk.

📌Core Message

In infants with head injuries, monitoring neurological status, spinal alignment, and intracranial changes is critical for early detection of deterioration.

Answer 2

Correct Answers

Blank 1 Correct Option: Stevens-Johnson syndrome
Blank 2 Correct Option: Skin rash

Rationale :

💊Phenytoin is associated with rare but life-threatening skin reactions, including Stevens-Johnson syndrome, especially when the drug level is subtherapeutic.

🌡️Dry, itchy, hyperpigmented patches with scratch marks may be an early presentation of a severe drug reaction, not just simple eczema.

💁‍♂️The end-expiratory wheeze and nonproductive cough are consistent with asthma, but the primary risk here is the skin involvement, not pulmonary complications.

🧴Skin rash is a hallmark of Stevens-Johnson syndrome and must prompt immediate evaluation to prevent progression to systemic involvement.

📌Core Message

A skin rash in a child on phenytoin may indicate Stevens-Johnson syndrome, a serious adverse effect requiring urgent attention.

Answer 3

Correct Answers:

The child prefers being with their friends rather than family

Rationale :

👥Preferring friends over family is developmentally appropriate for adolescents and does not usually indicate depression.

⚖️Weight changes (gain or loss) can be a sign of altered mood, appetite, or energy, commonly seen in depression.

🛌Excessive sleep or insomnia are classic symptoms of depression in adolescents and must be evaluated.

📉Declining academic performance can reflect decreased concentration, low motivation, or anhedonia, all related to depression.

📌Core Message

Adolescent depression is marked by changes in sleep, weight, and performance, not necessarily social preference.

Answer 4

Correct Answers:

Foster self-care activities.

Rationale :

👐Fostering self-care builds independence and promotes functional development, especially for children with hemiplegic cerebral palsy.

🧠While modifying the environment is important, it is secondary to building autonomy in daily tasks.

🗣️Improving communication is valuable but not the most urgent goal if the child already has basic communication skills.

🧩Respite care supports the family but does not directly impact the child's development, which is the nurse’s priority.

📌Core Message

For children with cerebral palsy, supporting self-care skills is a priority to foster independence and enhance quality of life.

Answer 5

Correct Answers:

"I only need to catheterize myself twice every day."

Rationale :

🧪Catheterizing only twice daily is inadequate for clients with neurogenic bladder, which can lead to urinary retention, UTIs, and renal damage.

🚽Intermittent catheterization is typically required every 4–6 hours to maintain bladder health and prevent complications.

🏋️‍♂️Wheelchair exercises promote circulation and muscle tone, which is appropriate.

💧High fluid intake and bowel programs using suppositories are standard management practices in clients with spina bifida.

📌Core Message

Children with spina bifida need consistent bladder management—infrequent catheterization can cause urinary complications.

Answer 6

Correct Answers:

"If child is not able to eat solid foods, you can offer fluids with some carbohydrates."
"Test the blood/urine for ketones."

Rationale :

🥣Offering fluids with carbohydrates helps maintain blood glucose during illness when solid food intake is poor.

🔬Testing for ketones in blood or urine helps monitor for diabetic ketoacidosis, a dangerous complication of illness in type 1 diabetes.

🚫Protein testing is not a relevant sick-day precaution—it’s more related to nephropathy screening.

🍭Fluids with sugar may actually be needed during hypoglycemia, so non-sugar fluids are not always appropriate.

💉Insulin should never be withheld, even during illness; the body may require more insulin due to stress hormones.

📌Core Message

During illness in type 1 diabetes, maintain glucose intake, test for ketones, and continue insulin therapy.

Answer 7

Correct Answers:

Perform a neurovascular assessment.

Rationale :

🦶Neurovascular assessment is essential to detect compartment syndrome, which can occur early after cast placement.

❄️Applying ice may help swelling but is not a priority over circulatory checks.

📖Discharge teaching and reassurance are important but should come after safety assessments.

🩺Assessment of pulses, sensation, and movement ensures tissue perfusion and should always be prioritized in clients with new casts.

📌Core Message

After cast application, performing a neurovascular assessment is the top priority to prevent limb ischemia.

Answer 8

Correct Answers:

SLE is an autoimmune disorder that I will always have, with times of flare-ups and times of minimal to no symptoms.

Rationale :

🔄Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with flares and remissions, not a condition that resolves permanently.

🌡️It can affect multiple systems, including the kidneys, joints, skin, and CNS—not just the skin.

💊There is no cure, but management with immunosuppressive drugs can reduce flares and inflammation.

🧬It is not strictly a rheumatic disease, although joint involvement is common.

📌Core Message

SLE is a lifelong autoimmune condition with flare-ups and systemic involvement that must be monitored long-term.

Answer 9

Correct Answers:

Place the child in isolation.

Rationale :

🦠Bacterial meningitis is highly contagious, and immediate droplet isolation is required to protect others and control spread.

💉Antibiotic therapy is important but should follow isolation and culture collection.

🩸Blood cultures are necessary but not as urgent as infection control.

🧪Lumbar puncture is needed for diagnosis but is not done until the child is stable and infection control is in place.

📌Core Message

In suspected bacterial meningitis, initiating isolation is the first and most critical step before diagnostics or treatment.

Answer 10

Correct Answers:

Airway obstruction

Rationale :

🔥Burns to the face, neck, and chest put the client at immediate risk for airway compromise due to swelling, which can develop rapidly.

💧Fluid loss is a major concern but occurs after airway threats are addressed.

🦠Infection is a longer-term complication and is not the immediate threat.

🥴Paralytic ileus may develop with stress or sepsis but is not the priority over maintaining the airway.

📌Core Message

In burn injuries involving the head and neck, airway obstruction is the most urgent and life-threatening risk.

ATI nur2708 Pediatrics Final Exam

No.

1 :
A nurse is caring for an infant in the emergency department.

Answer Options

2 :
A nurse is caring for a client.

Correct Answers

3 :
The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 :
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 :
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 :
An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 :
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 :
A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

ATI nur2708 Pediatrics Final Exam

No.

1 : A nurse is caring for an infant in the emergency department.

Answer Options

2 : A nurse is caring for a client.

Correct Answers

3 : The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 : A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 : A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 : A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 : A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 : An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 : A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 : A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

1 :
A nurse is caring for an infant in the emergency department.

2 :
A nurse is caring for a client.

3 :
The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 :
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 :
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 :
An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 :
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 :
A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?