Neuro/Behavioral
The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?
A. Meningitis
B. Spinal cord injury
C. Intracranial bleeding
D. Encephalitis
Answer: A
A. Meningitis
Rationale: A positive Kernig’s sign indicates meningeal irritation, which is most commonly associated with Meningitis.
A nurse is assessing a child with hyperthyroidism (Graves disease). Which finding should the nurse expect?
A. Weight gain
B. Bradycardia
C. Heat intolerance
D. Dry skin
Answer: C
C. Heat intolerance
Rationale: Hyperthyroidism causes heat intolerance, weight loss, tachycardia, and irritability.
The nurse is assessing a preadolescent girl for scoliosis. How would the nurse perform this assessment?
A. Place the girl on her back and flex the knees and observe for misalignment
B. Examine the girl unclothed from the waist down; examine movement of the hips and legs
C. Have the girl walk heel to toe and observe the gait and pelvis
D. Have the girl bend forward from the waist and observe for asymmetry in the back and hip area
Answer: D
D. Have the girl bend forward from the waist and observe for asymmetry in the back and hip area
Rationale: This is known as the Adams forward bend test, the standard screening method for scoliosis. When the child bends forward, the nurse looks for uneven shoulders, rib hump, or asymmetry in the spine and hips, which can indicate spinal curvature.
The nurse in the nursery is caring for a 24-hour-old infant. The nurse suspects the infant of having pyloric stenosis. Which of the following manifestations would support this finding?
A. Steatorrhea
B. Currant jelly stools
C. Projectile vomiting
D. Melena
Answer: C
C. Projectile vomiting
Rationale: Steatorrhea, currant jelly stools and melena are not manifestations of pyloric stenosis.
In which congenital heart defect would the nurse need to take upper and lower extremity blood pressures?
A. Coarctation of the Aorta (COA)
B. Tetralogy of Fallot (TOF)
C. Aortic stenosis (AS)
D. Transposition of the Great Vessels (Arteries)
Answer: A
A. Coarctation of the Aorta (COA)
Rationale: Coarctation of the Aorta (COA) is a narrowing of the aorta, typically just distal to the left subclavian artery.
The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) needs to be placed at the child's bedside?
A. Emergency cart
B. Tracheotomy set
C. Padded tongue blade
D. Suctioning equipment and oxygen
Answer: D
D. Suctioning equipment and oxygen
Rationale: Seizure precautions focus on airway protection and safety, making oxygen and suction equipment essential at the bedside.
A 12-year-old with Type 1 diabetes reports abdominal pain, fruity breath, and deep respirations. What complication should the nurse suspect?
A. Hypoglycemia
B. Diabetic ketoacidosis
C. Hyperosmolar syndrome
D. Insulin shock
Answer: B
B. Diabetic ketoacidosis
Rationale: Kussmaul respirations, fruity breath, and abdominal pain indicate DKA.
The nurse is developing a plan of care for a child recently diagnosed with cerebral palsy (CP). Which should be the nurse’s priority goal?
A) Teach appropriate parenting strategies for caregivers
B) Decrease intracranial pressure
C) Ensure the ingestion of sufficient calories for growth
D) Ensure that the child reaches full potential
Answer: D
D) Ensure that the child reaches full potential
Rationale: For chronic pediatric conditions like CP, think function and independence. The nurse's priority is to help the child achieve the highest possible developmental and functional potential, not to cure the disorder.
A newborn has abdominal distention and has not passed meconium within 48 hours. Which condition is suspected?
A. GERD
B. Pyloric stenosis
C. Hirschsprung disease
D. Intussusception
Answer: C
C. Hirschsprung disease
Rationale: Failure to pass meconium within 24–48 hours is a classic red flag for Hirschsprung disease.
The nurse is assessing a client diagnosed with ventricular septal defect (VSD), the nurse is aware that many infants with these conditions also receive a diagnosis of which of the following?
A. Trisomy 21
B. Turner syndrome
C. DiGeorge syndrome
D. Trisomy 18
Answer: A
A. Trisomy 21
Rationale: A ventricular septal defect (VSD) is one of the most common congenital heart defects and is frequently associated with Trisomy 21 (Down syndrome).
The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the parent will assist in providing information that will identify the symptoms associated with this type of seizure?
A. "Does twitching occur in the face and neck?"
B. "Does the muscle twitching occur on one side of the body?"
C. "Does the muscle twitching occur on both sides of the body?"
D. "Does the child have a blank expression during these episodes?"
Answer: D
D. "Does the child have a blank expression during these episodes?"
Rationale: Absence seizures present as brief staring spells with impaired awareness, not major muscle twitching.
A parent of a child with Type 1 Diabetes reports the child is sick with the flu. Which statement indicates correct understanding?
A. 'I will stop giving insulin until my child eats again.'
B. 'I will check blood glucose and ketones more often.'
C. 'I will only give insulin if the blood sugar is above 300.'
D. 'I will increase activity to lower blood sugar.'
Correct Answer: B
B. 'I will check blood glucose and ketones more often.'
Rationale: Illness increases risk of DKA; glucose and ketones should be checked frequently.
The nurse is reviewing the pathophysiology of Osgood-Schlatter disease. Which client would the nurse identify as being at highest risk of developing this disorder?
A) A 12-year-old boy who plays on the high school basketball and football teams
B) A 16-year-old boy who does not play any sports
C) An 8-year-old boy who does not play any sports
D) An 8-year-old African American girl
Answer: A
A) A 12-year-old boy who plays on the high school basketball and football teams
Rationale:
Besides a hip spica cast, what other devices are used in the treatment of hip dysplasia in a child?
A. Pavlik harness
B. Harrington rod
C. A large, rounded pillow
D. Reduction maneuver
Answer: A
A. Pavlik harness
Rationale: For treating hip dysplasia in infants, devices like the Pavlik harness or a hip spica cast are standard, depending on the child’s age and severity of the condition.
A newborn begins coughing, choking, and turning cyanotic during the first feeding. The nurse notices excessive drooling and frothy secretions. The nurse suspects esophageal atresia with tracheoesophageal fistula (EA/TEF). What is the priority nursing action?
A. Attempt to feed smaller amounts more frequently
B. Place the infant in a side-lying position and suction as needed
C. Insert an NG tube and begin gavage feedings
D. Lay the infant flat and administer oxygen
Answer: B
B. Place the infant in a side-lying position and suction as needed
Rationale: Side-lying positioning helps secretions drain and reduces aspiration risk.
Why the others are incorrect:
A. Feed smaller amounts
Feeding should be stopped immediately.
C. Insert NG tube and gavage feedings
In pure esophageal atresia, NG tube cannot pass into the stomach.
D. Lay infant flat
Flat positioning increases aspiration risk.
The nurse is caring for a child with a head injury. The nurse observes decerebrate posturing. What is the nurse's best action?
A. Notify the primary health care provider.
B. Document the finding.
C. Complete a head-to-toe examination.
D. Inform the family of the improved status.
Answer: A
A. Notify the primary health care provider.
Rationale: Decerebrate posturing is a serious neurologic sign indicating severe brain injury, often involving the brainstem. It is associated with increased intracranial pressure and possible deterioration.
This is a medical emergency, and the nurse’s priority is to report it immediately so rapid intervention can occur.
Which insulin has the fastest onset of action?
A. Regular insulin
B. NPH insulin
C. Lispro (Humalog)
D. Glargine (Lantus)
Correct Answer: C
C. Lispro (Humalog)
Rationale: Lispro is rapid-acting with onset of 15 minutes.
The nurse is providing education to the parent of a child diagnosed with Legg-Calves-Perthes disease. Which statement by the parent indicates teaching has been effective?
A) “I am so glad my child does not need a brace”
B) “I guess we will have to homeschool our child now”
C) “I will never give my child ibuprofen”
D) “My child may need surgery If the conservative treatments don’t help”
Answer: D
D) “My child may need surgery If the conservative treatments don’t help”
Rationale: For Legg-Calvé-Perthes disease, remember:
The nursing discharge care plan for a 2-month-old infant in a Pavlik harness includes what nursing measures?
A. Check at least two or three times a day for red areas under the straps
B. Instruct parents how to perform the Ortolani test daily
C. The parents may adjust the harness if they think it is necessary
D. Check with the healthcare provider about using a spica cast if the harness is not comfortable
Answer: A
A. Check at least two or three times a day for red areas under the straps
Rationale: The priority in Pavlik harness care is preventing skin breakdown and ensuring proper positioning
An emergency department nurse is caring for a 7-month-old infant with acute abdominal pain when the nurse begins to suspect intussusception. Which assessment finding would most support this suspicion?
A. Ribbon-like stools
B. Red, currant jelly-like stools
C. Greasy, foul-smelling stools
D. Black, tarry stools
Answer: B
B. Red, currant jelly-like stools
Rationales: Ribbon-like stools, greasy, foul-smelling stools or black, tarry stools are not seen in intussusception.
The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decorticate posturing. The nurse would modify the client's plan of care based on which interpretation of the client's change?
A. An insignificant finding
B. Decreasing intracranial pressure
C. An improvement in condition
D. Deteriorating neurological function
Answer: D
D. Deteriorating neurological function
Rationale: Any abnormal posturing in the context of increased ICP indicates neurologic deterioration and requires immediate attention.
The nurse is giving medication education to the parent of a child with newly diagnosed growth hormone deficiency. Which statement made by the parent indicates that further education is needed?
A. “I will give the subcutaneous medication every morning”
B. “I will need to give the medication every day”
C. “Treatment will continue until my child’s growth is complete”
D. “I will ask my child’s preference when choosing subcutaneous injection sites”
Answer: A
A. “I will give the subcutaneous medication every morning”
Answer Rationale: Growth hormone is given subcutaneously every night until the child's growth is complete. The child's growth plates in the bones will eventually close during puberty, and the growth hormone will no longer be effective. The other answers indicate understanding about the medication.
The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that mobility is greatly reduced. What is the most likely cause of the child’s impaired mobility?
A. Pathologic fractures
B. Poor alignment of joints
C. Joint inflammation
D. Dyspnea on exertion
Answer: C
C. Joint inflammation
Rationale: Juvenile rheumatoid arthritis (JRA) is an autoimmune disease that causes chronic joint inflammation. During an exacerbation (flare-up):
Joints become swollen, warm, and painful
Stiffness and pain limit movement
Children often refuse to use affected joints, reducing mobility
A 2-month old infant arrives at the pediatric clinic. Upon assessment, the baby exhibits the following characteristics. Which characteristics should the nurse relate to a diagnosis of congenital hypothyroidism? Select all that apply.
A. Hypotonia
B. Wide fontanels
C. Hypertonia
D. Tachycardia
E. Puffy face
Answers: A, B, E
A. Hypotonia
B. Wide fontanels
E. Puffy face
Rationale: Common findings include:
Hypotonia
Large/wide fontanels
Puffy face
Macroglossia (large tongue)
Poor feeding
Constipation
Prolonged jaundice
Bradycardia
Lethargy
Early treatment with levothyroxine is critical to prevent intellectual disability and developmental delay.
A toddler presents with intermittent abdominal pain, drawing knees to chest, and currant jelly stools. What is the priority action?
A. Administer oral laxative
B. Prepare for air enema
C. Start high-fiber diet
D. Encourage ambulation
Answer: B
B. Prepare for air enema
Rationale: Air enema is diagnostic and therapeutic for intussusception.
A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?
A. Implement seizure precautions.
B. Measure head circumference every shift.
C. Admit the client to a private room.
D. Place the client in a semi-Fowler's position.
Answer: B
B. Measure head circumference every shift.
Rationale: The head circumference of a 6-year-old can't increase since the fontanels and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head circumference.
An adolescent with type 1 diabetes mellitus is attending a dance in the school gym. The adolescent suddenly becomes flushed and complains of hunger and dizziness. The school nurse, who is present at the dance, takes the child to the nurse's office and performs a blood glucose level test that shows 60 mg/dL (3.4 mmol/L). Which is the initial nursing intervention?
A. Give the child ½ cup (120 ml) of a sugar-sweetened carbonated beverage
B. Call an ambulance to take the child to the hospital emergency department
C. Call the child's parents
D. Assist the child with administering regular insulin
Answer: A
A. Give the child ½ cup (120 ml) of a sugar-sweetened carbonated beverage
Rationale:The adolescent’s blood glucose level is 60 mg/dL, which indicates hypoglycemia (generally <70 mg/dL). Symptoms such as hunger, dizziness, and flushing are early signs of low blood glucose.
The initial nursing intervention is to provide 15 grams of fast-acting carbohydrates to quickly raise blood glucose levels. Examples include:
½ cup fruit juice
½ cup regular soda
Glucose tablets
Hard candy
After treatment, the blood glucose should be rechecked in about 15 minutes (the “15-15 rule”).
A child with a fractured tibia in a cast reports increasing pain. The extremity is pale, cool, and capillary refill is 4 seconds. What is the nurse’s priority action?
A. Elevate the extremity above heart level
B. Notify the provider immediately
C. Apply ice to the extremity
D. Administer pain medication and reassess in 30 minutes
Answer: B
B. Notify the provider immediately
Rationale: This child is showing classic signs of compartment syndrome, a surgical emergency:
Increasing pain (not relieved)
Pale extremity
Cool skin
Capillary refill > 3 seconds
A nurse is assessing a 2-month-old infant for developmental dysplasia of the hip (DDH). Which findings should the nurse recognize as possible manifestations of DDH? Select all that apply.
A. Unequal gluteal and thigh folds
B. Limited hip abduction on one side
C. Positive Ortolani maneuver (hip “click”)
D. Symmetrical leg lengths
E. One leg appearing shorter than the other
F. Bilateral equal range of motion
Answer/s: A, B, C, E
A. Unequal gluteal and thigh folds
B. Limited hip abduction on one side
C. Positive Ortolani maneuver (hip “click”)
E. One leg appearing shorter than the other
Rationale: A CLICKS = DDH”
Asymmetry (folds)
Click (Ortolani)
Limited abduction
Inequality (leg length)
Crease differences
Knee height difference
The nurse is assigned four children in the emergency department. Which child should be seen first?
A. A 3-year-old with barking cough and low-grade fever
B. A 2-year-old with drooling, muffled voice, and tripod positioning
C. A 6-month-old with wheezing and rhinorrhea
D. A 4-year-old with sore throat and sandpaper rash
Answer: B
B. A 2-year-old with drooling, muffled voice, and tripod positioning
Rationale: Drooling + muffled voice + tripod positioning = epiglottitis → impending airway obstruction → airway first.
Which of the following is an example of inattentiveness seen in an adolescent who has ADHD?
A) Difficulty completing their homework
B) Listening attentively
C) Difficulty staying seated in class
D) Difficulty waiting their turn
Answer: A
A) Difficulty completing their homework
Rationale:
B) Listening attentively: Not related
C) Difficulty staying seated in class: Example of hyperactivity
D) Difficulty waiting their turn: Example of impulsivity
The school nurse notices that a 14-year-old who used to be an excellent student and very active in sports is losing weight, and acting very nervous. The teen was recently checked by the primary care provider (PCP), who noted the teen had a very low level of TSH and elevated T3 and T4. The nurse recognizes that the teen has which condition?
A. Hashimoto thyroiditis
B. Grave's disease
C. Hypothyroidism
D. Cretinism
Answer: B
B. Grave's disease
Answer Rationale: Grave’s disease is hyperthyroidism and presents with low TSH levels, weight loss and excessive nervousness. Hashimoto thyroiditis is a term that refers to hypothyroid disease. Laboratory tests would reveal a high TSH level. Hypothyroidism is accompanied by a high TSH level. Juvenile autoimmune thyroiditis is a term referring to hypothyroid disease. Lab tests would reveal a high TSH level. The clues to the answer are the low TSH level and the child’s symptoms.
The nurse is providing education on Osgood-Schlatter disease to a child diagnosed with the disorder and the child's parents. The nurse states that Osgood-Schlatter disease is due to the inflammation of which anatomical structure?
A) Posterior cruciate ligament
B) Patellar tendon
C) Anterior cruciate ligament
D) Medial meniscus
Answer: B
B) Patellar tendon
Rationale: Think of Osgood-Schlatter disease as "patellar tendon pulling on the tibial tubercle." The repetitive traction leads to inflammation, tenderness, and a prominent, painful bump just below the kneecap.
The nurse is teaching the parents of a child diagnosed with eczema. Which of the following information should the nurse include? (Select All that Apply.)
A. "Wash the affected area 4-5 times/day"
B. "Baths with hot water are preferred"
C. "Keep the nails trimmed short"
D. "Apply lotion immediately after bathing"
E. "Avoid harsh soaps and detergents"
Answer/s: C, D, E
C. "Keep the nails trimmed short"
D. "Apply lotion immediately after bathing"
E. "Avoid harsh soaps and detergents"
Rationale: Key teaching points for eczema:
Gentle cleansing with lukewarm water
Moisturize immediately after bathing
Trim nails to prevent injury from scratching
Avoid harsh soaps, detergents, and irritants
A nurse is caring for an infant who is newly diagnosed with tetralogy of Fallot. Which actions from the box below are appropriate for the nurse to perform during a hypercyanotic spell? Select all that apply.
A. Place the infant in a knee-chest position.
B. Use a calm, comforting approach.
C. Administer oxygen.
D. Administer morphine.
E. Hold the infant upright at a 45-degree angle
Answer: A, B, C, D.
A. Place the infant in a knee-chest position.
B. Use a calm, comforting approach.
C. Administer oxygen.
D. Administer morphine.
Rationale: Hold the infant upright at a 45-degree angle is incorrect. This position does NOT increase systemic vascular resistance and will not reduce right-to-left shunting. The correct position is knee-chest, not upright.
A 4-year-old child, Liam, is brought in by his mother for a routine check-up. During the assessment, you notice that Liam appears anxious, avoids eye contact, and is unusually quiet. He flinches when you approach him to take his blood pressure.Upon examining his arms and back, you observe multiple bruises in varying stages of healing. Some bruises are in distinct patterns that raise concern. You gently ask Liam’s mother about the bruises, and she quickly responds, “Oh, he just fell off the swing while playing in the yard. He’s always getting into things.” However, the mother seems irritated when you ask more specific questions and avoids direct eye contact. Given this scenario and the information you have gathered, what should your next action be?
A. Immediately report the suspicion of child abuse to the appropriate authorities
B. Document the bruises and ask the mother for further details about the fall, then continue the examination
C. Explain to the mother that children often have bruises and reassure her that it is not a serious concern
D. Discharge the child with a follow-up appointment and advise the mother to monitor the bruises at home
Answer: A
A. Immediately report the suspicion of child abuse to the appropriate authorities
Rationale: In cases of suspected child abuse, prioritize child safety and follow mandated reporting laws. Suspicion alone is sufficient to trigger a report to child protective services.
A school nurse is assessing a student with Type 1 diabetes who is experiencing hypoglycemia. Which symptoms would the nurse expect?
Select all that apply.
A. Shakiness
B. Diaphoresis
C. Confusion
D. Fruity breath
E. Hunger
Correct Answers: A, B, C, E
A. Shakiness
B. Diaphoresis
C. Confusion
E. Hunger
Rationale:
A. Correct – Low glucose triggers sympathetic nervous system activation, causing tremors.
B. Correct – Sweating is a classic early symptom.
C. Correct – Brain cells rely on glucose, leading to confusion or irritability.
D. Incorrect – Fruity breath is associated with diabetic ketoacidosis (hyperglycemia), not hypoglycemia.
E. Correct – Hunger is a common early warning sign.
A child sustains a fall at home and is brought to the hospital emergency department by the child's parent. After a radiographic examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the parent regarding neurovascular assessment and function. Which statement by the parent indicates a need for further instruction?
A. "For the first couple of days, I would try to keep my child's hand higher than the heart most of the time using pillows."
B. "If my child seems way too fussy and complains of arm pain even after I've given the pain medication, it might be a problem, and I would call you for help to decide on what is happening."
C. "If my child's hand gets real cool and pale, I can apply the heating pad to it."
D. "I'll need to check my child's skin twice a day at the cast edges."
Answer: C
C. "If my child's hand gets real cool and pale, I can apply the heating pad to it."
Rationale: Coolness, paleness, or tingling of the fingers after a cast is applied can indicate impaired circulation or neurovascular compromise, which is a medical emergency. Applying a heating pad could worsen the problem or mask serious symptoms. The parent should instead notify the healthcare provider immediately.
The nurse has taught a client with acne self-management techniques. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
A. "I should squeeze my acne as soon as they appear"
B. "I should avoid sun tanning and use sunscreen"
C. "I should wash my face daily with a mild cleanser"
D. "I should sit in the sun more often to dry out my acne"
E. "I should avoid using oil-based products on my skin"
Answer/s: B, C, E
B. "I should avoid sun tanning and use sunscreen"
C. "I should wash my face daily with a mild cleanser"
E. "I should avoid using oil-based products on my skin"
Rationale: Key points for acne care:
Gentle cleansing
Avoid picking or squeezing
Use non-comedogenic (oil-free) products
Protect skin from sun exposure
The nurse working in the pediatric cardiac unit is reviewing the telemetry monitors for assigned clients. The nurse should initially plan to assess the client who is a:
A. 5-year-old child and is playing with other children in the playroom and has a pulse (P) of 110
B. 14-year-old adolescent and is resting in bed watching television and has a pulse (P) of 110
C. 2-year-old toddler and is sleeping and has a pulse (P) of 125
D. 3-month-old infant and has a fever and a pulse (P) of 148
Answer: B
B. 14-year-old adolescent and is resting in bed watching television and has a pulse (P) of 110
Rationale:
Normal Pediatric Heart Rates (approximate ranges):
Infant (0–12 months): 100–160 bpm
Toddler (1–3 years): 90–150 bpm
Preschooler (3–5 years): 80–140 bpm
School-age (6–12 years): 70–110 bpm
Adolescent (13–18 years): 60–100 bpm
Which nursing actions apply to the care of a child who is having a seizure? (Select All that Apply.)
A. Restrain the child.
B. Time the seizure.
C. Place the child in a lateral side-lying position.
D. Loosen clothing around the child's neck.
E. Stay with the child.
F. Insert an oral airway.
Answer: B, C, D, E
B. Time the seizure.
C. Place the child in a lateral side-lying position.
D. Loosen clothing around the child's neck.
E. Stay with the child.
Rationale: During a seizure, the priority is airway safety, preventing injury, observation, and support, not restraint or oral insertion.
A 16-year-old presents with irregular menses, hirsutism, and moderate acne. The healthcare provider suspects polycystic ovary syndrome (PCOS). Which additional assessment findings would the nurse expect based on the underlying pathophysiology of PCOS? Select all that apply.
A. Acanthosis nigricans on the neck and axillae
B. Elevated fasting insulin levels
C. Persistent hypotension
D. Obesity or increased central adiposity
E. Elevated androgen levels
Answer/s: A, B, D, E
A. Acanthosis nigricans on the neck and axillae
B. Elevated fasting insulin levels
D. Obesity or increased central adiposity
E. Elevated androgen levels
Rationale: Think of PCOS as a cycle of:
Insulin resistance → Hyperinsulinemia → Increased ovarian androgen production → Chronic anovulation → Irregular menses, hirsutism, acne, with an increased risk for metabolic syndrome and type 2 diabetes mellitus.
Which statements by a parent indicate correct understanding of cast care? Select all that apply.
A. “I will use a hairdryer on warm for itching.”
B. “I can insert a pencil to scratch inside the cast.”
C. “I should check for numbness or tingling.”
D. “I will elevate the extremity above heart level initially.”
E. “Warm air helps dry the cast faster.”
Answer/s: C, D
C. “I should check for numbness or tingling.”
D. “I will elevate the extremity above heart level initially.”
Rationale: For cast care:
Neurovascular checks = critical
Elevation early
Nothing goes inside the cast
No heat
The nurse explains to the parents of a child with atopic dermatitis (eczema) that the condition may be associated with which problems? Select all that apply.
A. Bronchitis
B. Asthma
D. Impetigo
E. Allergic rhinitis
F. Sinus infections
Answer/s: B, E
B. Asthma
E. Allergic rhinitis
Rationale: Think “Atopic march” → eczema → food allergies → asthma → allergic rhinitis
A nurse in the pediatric emergency department is assessing four children. Which child should the nurse assess first?
A. A 6-month-old with RSV who has RR 58, moderate subcostal retractions, and O₂ saturation 93% on room air
B. A 3-year-old with croup who has inspiratory stridor only when crying
C. A 5-year-old with asthma who has decreased wheezing compared to 1 hour ago, RR 34, and is now lethargic
D. A 2-year-old with suspected foreign body aspiration who is coughing forcefully and crying
Answer: C
C. A 5-year-old with asthma who has decreased wheezing compared to 1 hour ago, RR 34, and is now lethargic
Rationale: This is the most dangerous presentation.
This suggests:
Impending respiratory failure
“Silent chest” progression
Possible ventilatory collapse
This child needs immediate intervention.
Why the Others Are NOT First
A. RSV infant with RR 58, O₂ 93%
Tachypneic but oxygenation still acceptable
Moderate retractions expected in bronchiolitis
Not crashing
B. Croup with stridor only when crying
Stridor at rest would be severe
Stridor only when crying = mild/moderate
Not priority over impending failure
D. Foreign body aspiration, coughing forcefully
Crying + coughing = airway still open
DO NOT interfere
Partial obstruction = better than no air movement
Which findings are early signs of increased intracranial pressure in infants? Select all that apply.
A. Decreased consciousness
B. High-pitched cry
C. Bulging fontanelle
D. Bradycardia
E. Irritability
Answer/s: B, C, E
B. High-pitched cry
C. Bulging fontanelle
E. Irritability
Rationale:
Think EARLY = subtle neuro changes
→ irritability, cry changes, feeding issues
Think LATE = deterioration
→ ↓ LOC, bradycardia, apnea
A 13-year-old with Type 1 diabetes arrives at the emergency department with the following findings:
Blood glucose: 420 mg/dL
Kussmaul respirations
Fruity breath
Lethargy
Which physician order should the nurse implement first?
A. Administer IV regular insulin
B. Begin IV normal saline infusion
C. Administer sodium bicarbonate
D. Give oral glucose
Correct Answer: B
B. Begin IV normal saline infusion
Rationale: This child is experiencing diabetic ketoacidosis (DKA).The first priority treatment is fluid resuscitation with IV normal saline to correct dehydration and improve circulation before insulin therapy.
Fluids are given before insulin in diabetic ketoacidosis (DKA) because the child is usually severely dehydrated, and restoring circulation is the first priority for safety.
A child returns from spinal fusion surgery for scoliosis. Which interventions are appropriate? Select all that apply.
A. Use log-rolling technique
B. Encourage twisting to reposition
C. Monitor neurovascular status
D. Maintain spinal alignment
E. Allow independent ambulation immediately
Answer/s: A, C, D
A. Use log-rolling technique
C. Monitor neurovascular status
D. Maintain spinal alignment
Rationale: After spinal surgery: Think “NO BLT”
Bending
Lifting
Twisting
The nurse is educating the parent of a child diagnosed with impetigo. Which of the following statements, if made by the parent, would indicate effective understanding? (Select All that Apply.)
A. "My child should wear a mask in public to prevent others from getting sick"
B. "The virus causing this condition may cause skin outbreaks from time to time"
C. "I should keep the draining blisters uncovered"
D. "I should keep my child home from swim practice until the blisters heal"
E. "I should not share my child's linens with anyone else in the house"
Answer/s: D, E
D. "I should keep my child home from swim practice until the blisters heal"
E. "I should not share my child's linens with anyone else in the house"
Rationale: Impetigo is a highly contagious bacterial skin infection, usually caused by Staphylococcus aureus or Streptococcus pyogenes. Parent education focuses on preventing the spread and promoting healing.
A nurse is caring for four pediatric clients. Which child should the nurse assess first?
A. A 4-year-old with celiac disease who has abdominal bloating
B. A 2-year-old with intussusception who suddenly becomes lethargic
C. A 6-month-old with GERD who spits up small amounts
D. A 5-year-old with constipation who has not had a bowel movement in 3 days
Answer: B
B. A 2-year-old with intussusception who suddenly becomes lethargic
Rationale: This may indicate:
Bowel perforation
Shock
Severe obstruction
Sepsis
Lethargy in pediatrics is a major red flag.
Why not the others?
A. Bloating is expected in celiac.
C. Mild spit-up is common.
D. Constipation for 3 days is uncomfortable but not emergent.