Question

A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?

Answer 1

Correct Answers:

Sweat chloride test

Rationale :

🧪 The sweat chloride test is the gold standard diagnostic test for cystic fibrosis (CF).

🧪 It measures the concentration of chloride in the child's sweat, which is elevated due to a defect in the CFTR gene affecting chloride transport.

🧪 A chloride level >60 mEq/L on two separate tests is diagnostic for CF.

🧪 This test is noninvasive, reliable, and typically performed at specialized centers using pilocarpine iontophoresis to stimulate sweating.

🧪 While other tests (e.g., stool fat, sputum culture, or pulmonary function) support the diagnosis or monitor progression, they do not confirm CF alone.

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Answer 2

Correct Answers:

"This test will confirm if your child had a recent streptococcal infection."

Rationale :

🧬 The anti-streptolysin O (ASO) titer detects antibodies produced in response to streptolysin O, an enzyme released by group A beta-hemolytic streptococcus.

🧬 A high ASO titer suggests a recent streptococcal infection, which supports the diagnosis of rheumatic fever, a post-infectious inflammatory disease.

🧬 It is not used to measure antibiotic levels or immunity. Instead, it helps confirm if the triggering infection occurred, which is crucial for diagnosing RF.

🧬 This test is particularly valuable when a prior throat infection was untreated or undocumented.

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Answer 3

Correct Answers:

Increased blood pressure in the arms with decreased blood pressure in the legs

Rationale :

❤️ Coarctation of the aorta is a congenital narrowing of the aortic arch, typically distal to the subclavian artery.

❤️ This narrowing leads to increased pressure proximal to the defect (upper extremities) and decreased pressure distal to it (lower extremities).

❤️ Clinical signs include bounding pulses in arms, weak or absent femoral pulses, and cool lower limbs.

❤️ Recognizing this gradient is key in identifying coarctation and differentiating it from other cardiac anomalies.

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Answer 4

Correct Answers:

"Distributive shock occurs due to systemic vasodilation."

Rationale :

🩸 Distributive shock, including anaphylactic, neurogenic, and septic shock, is caused by massive vasodilation leading to relative hypovolemia and decreased tissue perfusion.

🩸 In anaphylaxis, histamine release causes widespread vasodilation and increased capillary permeability.

🩸 This results in hypotension despite normal or increased blood volume, which impairs oxygen delivery.

🩸 The hallmark of distributive shock is vasodilation, not fluid loss or impaired contractility (which are seen in hypovolemic and cardiogenic shock).

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Answer 5

Correct Answers:

Have the client remain in bed up to 6 hr.
Check peripheral pulses in the affected extremity.
Keep the client's hip and leg extended.

Rationale :

✅ A. Have the client remain in bed up to 6 hours.

🛌 After cardiac catheterization—especially when the femoral artery is used—the patient is typically placed on strict bedrest for 4–6 hours to prevent bleeding or hematoma formation at the insertion site.

🛌 During this time, the nurse must monitor for signs of bleeding, such as swelling, pain, or visible blood at the site.

🛌 Ambulation too soon can lead to arterial disruption, especially if the catheter site is not adequately clotted or sealed.

🛌 The duration of bedrest may be modified based on the size of the sheath used, closure device applied, and provider-specific protocols.

✅ B. Check peripheral pulses in the affected extremity.

🛌 It is crucial to assess the circulatory status of the limb used for catheter access (typically the leg) by checking pedal or posterior tibial pulses.

🛌 Diminished or absent pulses may indicate vascular occlusion, thrombosis, or arterial spasm, which are serious complications of catheterization.

🛌 Additional signs like cool skin, pallor, or delayed capillary refill should also be assessed and reported immediately.

🛌 Frequent checks (e.g., every 15 minutes initially) are essential in the first 1–2 hours post-procedure, then spaced as the patient stabilizes.

✅ D. Keep the client’s hip and leg extended.

🛌 Keeping the affected extremity straight and immobilized minimizes strain on the puncture site and helps prevent bleeding or hematoma formation.

🛌 Flexing the hip, especially in the first 4–6 hours, can place pressure on the catheter site and disrupt clot formation, increasing the risk of hemorrhage.

🛌 Positioning the client with the head of the bed no higher than 30 degrees supports comfort while maintaining safe alignment.

🛌 This is especially important for children and restless patients, who may require soft restraints or parental assistance to keep the leg still.

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Answer 6

Correct Answers:

Provide privacy during personal care and procedures.
Show respect for the client's feelings and concerns.
Listen carefully to the client's thoughts and concerns regarding their hospitalization.

Rationale :

✅ A. Provide privacy during personal care and procedures.

🧑‍⚕️ Adolescents are especially sensitive to body image and personal boundaries due to the rapid physical changes of puberty.

🧑‍⚕️ Ensuring privacy helps preserve dignity and autonomy, which are critical to their emotional development.

🧑‍⚕️ Providing a gown, closing curtains, and limiting exposure during exams respects their need for modesty.

🧑‍⚕️ This approach reduces embarrassment and anxiety, which improves trust and cooperation during care.

✅ E. Show respect for the client's feelings and concerns.

🧑‍⚕️ Adolescents value being treated as individuals with valid emotions and emerging independence.

🧑‍⚕️ Acknowledging their feelings about hospitalization, treatment, or body changes fosters rapport and emotional safety.

🧑‍⚕️ Respectful communication supports their growing sense of identity and confidence in navigating health decisions.

🧑‍⚕️ It also helps reduce feelings of isolation or vulnerability, especially in an adult care setting where they may feel overlooked.

✅ F. Listen carefully to the client's thoughts and concerns regarding their hospitalization.

🧑‍⚕️ Active listening builds trust and helps the adolescent feel heard and involved in their care.

🧑‍⚕️ Adolescents are developing critical thinking and want their concerns to be taken seriously.

🧑‍⚕️ Giving them space to express fears or ask questions empowers them and promotes shared decision-making.

🧑‍⚕️ It also helps the nurse identify emotional distress, misconceptions, or knowledge gaps to address therapeutically.

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Answer 7

Correct Answers:

"Taking the medication between meals will help you absorb the medication more efficiently."

Rationale :

🩸 Ferrous sulfate is best absorbed in an acidic environment, which is more available on an empty stomach.

🩸 Taking it between meals avoids interaction with food components like calcium, fiber, and tannins, which can inhibit iron absorption.

🩸 Although it may cause mild gastrointestinal upset, the priority is to maximize iron uptake for effective treatment of anemia.

🩸 If GI discomfort becomes significant, the provider may adjust timing or recommend taking it with a small amount of vitamin C-rich juice to aid absorption.

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Answer 8

Correct Answers:

Give the child acetaminophen for discomfort.

Rationale :

💊 Acetaminophen is recommended post–cardiac catheterization for managing mild pain or soreness at the insertion site.

💊 It is safe and effective for children, with fewer gastrointestinal side effects compared to NSAIDs like ibuprofen, especially after a procedure.

💊 Discomfort is often localized and mild but should be addressed to promote rest and recovery.

💊 Parents should be instructed on appropriate dosing based on the child’s weight and to monitor for signs of increased pain, bleeding, or infection, which would require prompt medical attention.

💊 Managing pain effectively also encourages early mobility and reduces anxiety in pediatric clients.

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Answer 9

Correct Answers:

Ability to perform logical operations on concrete
Understanding the concept of conservation

Rationale :

✅ C. Ability to perform logical operations on concrete objects

🧠 During the concrete operational stage, children gain the ability to apply logic and reasoning to tangible, physical objects and real-life situations.

🧠 This includes understanding cause and effect, organizing objects by multiple attributes (such as size and shape), and solving concrete problems.

🧠 However, their thinking is still bound to the "here and now"—they cannot yet effectively handle abstract or hypothetical concepts.

🧠 This ability marks a major shift from earlier stages, where thought was more intuitive and perception-bound.

🧠 For example, they can solve math problems using objects (e.g., adding apples), but may struggle with abstract algebra.

✅ D. Understanding the concept of conservation

🧠 Conservation is the understanding that quantity remains the same despite changes in shape or appearance—a hallmark milestone of this stage.

🧠 School-aged children begin to realize that liquid in a tall glass is not "more" than the same amount in a short, wide glass.

🧠 This reflects improved reversibility and decentering—they can think through changes and reverse mental steps to understand outcomes.

🧠 This concept extends to conservation of number, mass, volume, and area, all of which are crucial in academic learning.

🧠 It shows that children are no longer fooled by superficial appearances and can reason more logically about physical reality.

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Answer 10

Correct Answers:

Varicella (VAR)

Rationale :

💉 At 4 years old, children typically receive the second dose of the varicella vaccine as part of the routine immunization schedule.

💉 This booster helps ensure long-term immunity against chickenpox, a highly contagious viral disease.

💉 Other vaccines due at this age include the DTaP, IPV, and MMR boosters.

💉 Meningococcal (MCV4) is usually given at 11–12 years, HepB and Hib are completed by 18 months.

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RN ATI Pediatrics Unit II Exam

No.

1 :
A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?

2 :
A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?

3 :
A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

4 :
A nurse and a newly licensed nurse are providing care for a client who has distributive shock related to an anaphylactic reaction. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?

5 :
A nurse is caring for a client who just returned from a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)

6 :
A nurse is providing care to an adolescent client who is hospitalized in an adult setting. Which of the following interventions by the nurse supports a client experiencing emotional and physical changes of puberty? (Select all that apply.)

7 :
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?

8 :
A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

9 :
Which of the following cognitive abilities are characteristic of a school-aged child in Piaget's concrete operational stage? (select all that apply)

10 :
A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?

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RN ATI Pediatrics Unit II Exam

No.

1 : A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?

2 : A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?

3 : A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

4 : A nurse and a newly licensed nurse are providing care for a client who has distributive shock related to an anaphylactic reaction. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?

5 : A nurse is caring for a client who just returned from a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)

6 : A nurse is providing care to an adolescent client who is hospitalized in an adult setting. Which of the following interventions by the nurse supports a client experiencing emotional and physical changes of puberty? (Select all that apply.)

7 : A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?

8 : A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

9 : Which of the following cognitive abilities are characteristic of a school-aged child in Piaget's concrete operational stage? (select all that apply)

10 : A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?

1 :
A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?

2 :
A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?

3 :
A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

4 :
A nurse and a newly licensed nurse are providing care for a client who has distributive shock related to an anaphylactic reaction. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?

5 :
A nurse is caring for a client who just returned from a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)

6 :
A nurse is providing care to an adolescent client who is hospitalized in an adult setting. Which of the following interventions by the nurse supports a client experiencing emotional and physical changes of puberty? (Select all that apply.)

7 :
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?

8 :
A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

9 :
Which of the following cognitive abilities are characteristic of a school-aged child in Piaget's concrete operational stage? (select all that apply)

10 :
A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?