ATI Peds ATI 2019 B with NGN/rationales A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use?
- FACES
- Numeric
- CRIES
- Visual analog - ANSWER A
The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management.A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?
a. "allow your child to play outside during the hours between 10:00am and
2:00pm."
- "choose a waterproof sunscreen with a minimum SPF of 15." 1 / 4
- "dress you child in loose weave polyester fabric prior to sun exposure."
- "reapply sunscreen every 4 hours." - ANSWER
- an 18 month old toddler who has unintelligible speech
- a 3 month old infant who has exaggerated startle response
- a 4 year old preschooler who prefers playing with others rather than alone
- an 8 month old infant who is not yet making babbling sounds - ANSWER
B The nurse should instruct parents to avoid allowing their children to play outside during the hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn during this time.The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn.The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun.The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.A nurse is performing hearing screenings for children at a community health fair.Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?
D The nurse should refer a toddler who does not possess intelligible speech by the age of 24 months to a provider for a more extensive evaluation of hearing. 2 / 4
The nurse should refer infants who are under the age of 4 months and lack a startle response to a provider for a more extensive evaluation of hearing.The nurse should refer a preschooler who prefers playing alone and avoids interaction with others to a provider for a more extensive evaluation of hearing.The nurse should refer an infant who is not making babbling sounds by the age of
- months to a provider for a more extensive evaluation of hearing.
- HR 124
- increased tear production
- sunken anterior fontanel
- capillary refill 2 seconds - ANSWER C
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?
A heart rate of 124/min is within the expected reference range of 106 to 186/min for a 3- to the 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia.An infant who has moderate to severe dehydration is more likely to have an absence of tears rather than increased tear production.The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. 3 / 4
A capillary refill of 2 seconds is within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have a delayed capillary refill of greater than 2 seconds.A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching?
- "limit movement of the child's large joints"
- "encourage the child to perform independent self-care."
- "provide the child with a soft mattress for sleeping."
- "schedule a 2 hour daily nap for the child in the afternoon." - ANSWER
- / 4
B "Limit movement of the child's large joints."Large joints should be exercised regularly to maintain mobility and strengthen muscles."Encourage the child to perform independent self-care."MY ANSWERThe nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem."Provide the child with a soft mattress for sleeping."Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position.