ATI Nursing Care of Children

Correct Answer: A

Rationale: The Snellen letter chart is the most commonly used test for measuring visual acuity, particularly in school-age children and adults.

Correct Answer: B

Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.

Correct Answer: C

Rationale: In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.

Correct Answer: C

Rationale: The child's developmental level is the most important factor, as it determines how information should be communicated and what the child can understand.

Correct Answer: C

Rationale: A murmur is produced by turbulent blood flow within the heart or major arteries, resulting in audible vibrations.