Eyes/Ears/Behavioral
A child with amblyopia is prescribed patch therapy. What is the goal of this treatment?
A. Improve eye muscle tone
B. Force use of the weaker eye
C. Reduce intraocular pressure
D. Prevent retinal detachment
Answer: B
B. Force use of the weaker eye
Rationale: Patching the strong eye forces the brain to use the weaker eye, strengthening vision.
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.
Which parent statement indicates understanding of pancreatic enzyme therapy for cystic fibrosis?
A. “I will give enzymes at bedtime only.”
B. “I will give enzymes with every meal and snack.”
C. “Enzymes are only needed during illness.”
D. “I will crush enzymes and mix with hot food.”
Answer: B
B. “I will give enzymes with every meal and snack.”
Rationale: Enzymes must be given with all meals/snacks to promote digestion.
A 3-month-old infant presents with a history of vomiting after feeding. The plan for the infant is to rule out GERD. What information from the history would lead the nurse to believe that this infant may need further intervention?
A. Small "spits" after feedings
B. Sleeps through the night
C. Absence of nausea/vomiting
D. Poor weight gain
Answer: D
D. Poor weight gain
Rationale: Many infants have normal reflux because:
Lower esophageal sphincter is immature
They spend most of their time supine
They consume liquid diets
However, GERD becomes concerning when it affects growth and health.
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.
A 6-month-old infant has persistent tearing and crusting of the eye without redness or swelling. What is the nurse’s best intervention?
A. Start antibiotic eye drops
B. Teach nasolacrimal duct massage
C. Patch the affected eye
D. Schedule immediate surgery
Answer: B
B. Teach nasolacrimal duct massage
Rationale: Nasolacrimal duct obstruction is common in infants and is managed with lacrimal sac massage.
The nurse is caring for a child admitted with congestive heart failure. Which of the following assessment findings would be expected?
A. Flattened neck veins
B. Bradypnea
C. Pulse deficit
D. Exercise intolerance
Answer: D
D. Exercise intolerance
Rationale: In pediatric congestive heart failure (CHF), the heart is unable to pump effectively to meet the body’s metabolic demands. As a result, tissues receive inadequate oxygen during activity.
A classic and early finding in children with CHF is:
Fatigue with feeding (infants)
Poor weight gain
Exercise intolerance (older children)
Tachycardia
Tachypnea
Diaphoresis with activity
A child 8 hours post-tonsillectomy is swallowing frequently and appears restless. What is the nurse’s priority action?
A. Offer red popsicles
B. Assess for bleeding
C. Administer ibuprofen
D. Encourage coughing
Answer: B
B. Assess for bleeding
Rationale: Frequent swallowing indicates bleeding.
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.
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.
A nurse assesses a teenager suspected of bulimia nervosa. Which finding is most likely?
A. Severe weight loss
B. Dental enamel erosion
C. Amenorrhea
D. Bradycardia
Answer: B
B. Dental enamel erosion
Rationale: Frequent vomiting causes dental erosion and parotid gland swelling.
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).
An adolescent with asthma suddenly has absent breath sounds, increasing respiratory rate, and appears anxious. What should the nurse do first?
A. Encourage coughing
B. Administer inhaled corticosteroid
C. Activate rapid response
D. Provide oral fluids
Answer: C
C. Activate rapid response
Rationale: A silent chest indicates severe obstruction and impending respiratory failure. This is an emergency.
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 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.
A nurse is screening a toddler for autism spectrum disorder. Which behavior is most concerning?
A. Limited eye contact
B. Playing with toys independently
C. Fear of strangers
D. Using gestures to communicate
Answer: A
A. Limited eye contact
Rationale: Poor eye contact and lack of social interaction are early autism signs.
The nurse is caring for a child diagnosed with a coarctation of the aorta who is scheduled for a surgical repair tomorrow morning. When the nurse auscultates the child's lungs sounds, the nurse notes diffuse crackles and rales throughout the lung fields. The nurse interprets this assessment as which of the following?
A. Systemic congestion
B. Foreign body aspiration
C. Pulmonary congestion
D. Pneumonia
Answer: C
C. Pulmonary congestion
Rationale:
Coarctation of the aorta causes increased afterload and left ventricular pressure. Over time, the left ventricle struggles to pump effectively against the narrowed aorta. When the left side of the heart begins to fail, blood backs up into the lungs.
Which is the earliest recognizable manifestation of cystic fibrosis?
A. Recurrent pneumonia
B. Steatorrhea
C. Meconium ileus
D. Clubbing
C. Meconium ileus
Rationale:
Meconium ileus is often the earliest clinical manifestation of cystic fibrosis and may present in the newborn period.
The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease?
A. Turkey salad, milk, and oatmeal cookies
B. Baked chicken, coleslaw, soda, and frozen fruit dessert
C. Turkey sandwich on rye bread, orange juice, and fresh fruit
D. Tuna salad sandwich on whole wheat bread, milk, and ice cream
Answer: B
B. Baked chicken, coleslaw, soda, and frozen fruit dessert
Rationale: Gluten free diet. No oatmeal, no rye, no wheat.
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.
When attention deficit hyperactivity disorder (ADHD) is present, the child will most likely exhibit which core symptoms?
A. Overly friendly, able to follow directions, impulsive, and active
B. Affective disturbances, autism, psychosis, and excessive talkativeness
C. Highly distractible, excitable, impulsive, and excessively active
D. Quiet, impulsive, excessively attentive, and psychotic
Answer: C
C. Highly distractible, excitable, impulsive, and excessively active
Rationale: Children with ADHD present with high distractibility, hyperactivity, impulsivity and excitability.
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 2-year-old presents with drooling, inspiratory stridor, tripod positioning, and sudden onset of high fever. What is the nurse’s priority action?
A. Obtain a throat culture
B. Place the child supine for assessment
C. Prepare for possible intubation
D. Administer a nebulized bronchodilator
Answer: C
C. Prepare for possible intubation
Rationale: Findings indicate acute epiglottitis. Airway obstruction is the priority. Do NOT visualize the throat.
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 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.
Which of the following is an example of inattentiveness seen in an adolescent who has ADHD?
A. Difficulty completing their homework
B. Difficulty waiting their turn
C. Difficulty staying seated in class
D. Listening attentively
Answer: A
A. Difficulty completing their homework
Rationale: A common sign of ADHD is the inability to finish assignments, follow through on instructions, or stay mentally engaged in tasks, such as homework.
Difficulty waiting their turn → Impulsivity
Difficulty staying seated in class → Hyperactivity
To prevent infective endocarditis in the child with an artificial heart valve, the nurse teaches parents to:
A. Administer prophylactic antibiotics before dental work.
B. Immediately treat unexplained fevers with acetaminophen.
C. Avoid raw fruits and vegetables.
D. Avoid spending time with household pets.
Answer: A
A. Administer prophylactic antibiotics before dental work.
Answer Rationale: Dental procedures may allow organisms to enter the child’s bloodstream and grow on the artificial valve. This makes excellent oral hygiene also important. Unexplained fevers should be discussed with the child’s health care provider and not automatically treated at home. Raw fruits and vegetables and household pets are not a particular threat to this child.
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.
A 10-month-old with vomiting and diarrhea has dry mucous membranes, pulse slightly increased, sunken fontanelle, and decreased urine output. These findings indicate:
A. Mild dehydration
B. Moderate dehydration
C. Severe dehydration
D. Normal infant variation
Answer: B
B. Moderate dehydration
Rationale:
Moderate dehydration signs:
Dry mucosa
Sunken fontanelle
Decreased tears
Reduced urine output
Pulse slight increased
Severe: Parched mucous membranes, very increased pulse, hypotension.
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”).
During a discussion with the school nurse, a 13-year-old student states, "I hate myself. I just want to die." Which of the following responses should the nurse make?
A. "You don't really mean that, don't say it"
B. "You say that you want to die. Do you have a plan about how you might end you life?"
C. "You are scaring me with those comments, please stop it"
D. "You can't do that. Have you thought about how much that would affect your parents?"
Answer: B
B. "You say that you want to die. Do you have a plan about how you might end your life?"
Rationale: When a child or adolescent expresses suicidal ideation, the nurse must take the statement seriously and assess the level of risk immediately. The appropriate response is to ask direct questions about suicidal intent and whether the student has a plan.
Research shows that asking directly about suicide does not increase the risk of suicide; instead, it helps the nurse determine the immediacy of danger and initiate safety interventions.
A child with heart failure is receiving digoxin. Which finding requires immediate action?
A. Apical pulse 92 in a 4-year-old
B. Serum potassium 3.0 mEq/L
C. Mild nausea
D. Increased appetite
Answer: B
B. Serum potassium 3.0 mEq/L
Rationale: Digoxin toxicity risk increases with hypokalemia.
A 5-year-old with asthma is admitted. Which findings indicate impending respiratory failure? (Select all that apply.)
A. Wheezing
B. Silent chest
C. Increased respiratory rate
D. Sudden decrease in wheezing
E. Restlessness
Answers: B, C, D, E
B. Silent chest
C. Increased respiratory rate
D. Sudden decrease in wheezing
E. Restlessness
Rationale:
Silent chest = minimal air movement (very bad sign)
Sudden decrease in wheezing may mean airway is too constricted for airflow
Tachypnea + restlessness = hypoxia
Wheezing alone does not equal failure.
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 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.
A 4-year-old child is diagnosed with otitis media. The parent asks the nurse about the causes of this illness. Which risk factors would the nurse include in response to this parent? Select all that apply.
A. Household smoking
B. A history of urinary tract infections
C. Exposure to illness in daycare centers or schools
D. Congenital conditions such as cleft palate
E. Bottle-feeding
Answers: A, C, D, E
A. Household smoking
C. Exposure to illness in daycare centers or schools
D. Congenital conditions such as cleft palate
E. Bottle-feeding
Rationale: Common pediatric risk factors for otitis media include:
Secondhand smoke
Daycare exposure
Bottle-feeding
Craniofacial abnormalities (cleft palate)
Frequent upper respiratory infections
Age under 2 years
A nurse is assessing an infant diagnosed with patent ductus arteriosus (PDA). Which finding is most consistent with this condition?
A. Harsh systolic murmur
B. Continuous “machinery-like” murmur
C. Absent femoral pulses
D. Cyanosis with crying
Answer: B
B. Continuous “machinery-like” murmur
Rationale:
PDA is an acyanotic defect caused by failure of the ductus arteriosus to close after birth.
Classic findings include:
Continuous “machinery-like” murmur
Bounding pulses
Wide pulse pressure
Signs of heart failure in larger defects
A 4-month-old with RSV is admitted. Which nursing interventions are appropriate? (Select all that apply.)
A. Initiate contact precautions
B. Perform frequent nasal suctioning
C. Encourage large volume oral feedings
D. Continuous pulse oximetry
E. Administer prophylactic antibiotics
Answers: A, B, D
A. Initiate contact precautions
B. Perform frequent nasal suctioning D. Continuous pulse oximetry
Rationale: RSV management is supportive with suctioning, O₂ monitoring, and contact precautions. Antibiotics are not indicated for viral infections.
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.
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 nurse in the pediatric clinic receives several calls from parents. Which child should the nurse instruct to be brought to the clinic immediately?
A. A 4-year-old with bacterial conjunctivitis and yellow eye drainage
B. A 7-year-old reporting blurred vision after being hit in the eye with a baseball
C. A 6-year-old with itching and watery eyes during pollen season
D. A 3-year-old with mild tearing from nasolacrimal duct obstruction
Correct Answer: B
B. A 7-year-old reporting blurred vision after being hit in the eye with a baseball
Rationale: Blurred vision after eye trauma may indicate retinal injury or internal eye damage, which is an ophthalmologic emergency requiring immediate evaluation.
A → bacterial conjunctivitis (urgent but not emergency)
C → allergic conjunctivitis
D → common benign condition in infants
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
A nurse is caring for an adolescent who is newly diagnosed with asthma. Which instructions from the box below should the nurse include in the discharge plan of care? Select all that apply:
A. Encourage the child to avoid triggers.
B. Encourage the child to use a peak expiratory flow meter.
C. Encourage the child to play sports that require short bursts of energy.
D. Encourage the child to keep an epinephrine auto-injector pen with them at all times.
E. Encourage the child to rinse their mouth after use of a metered-dose inhaler (MDI).
F. Encourage the child to use a long-term medication in an emergency
Answer: A, B, C & E
Rationale: Key Asthma Teaching Reminders:
Avoid triggers
Use peak flow meter
Carry rescue inhaler at all times
Rinse mouth after steroids
Use SABA for acute symptoms
Encourage appropriate exercise
A mother brings her 5-month-old infant to the clinic. The child has been vomiting since early morning and has had diarrhea since the day before. His temperature is 100.1 F, pulse 140, and respiratory rate 38. He has lost 6 oz since his well-child visit 4 days ago. He cries before passing a bowel movement, he will not breastfeed today. What is the priority nursing diagnosis?
A. Thermoregulation alteration
B. Fluid volume deficit related to excessive losses and inadequate intake
C. Abdominal pain related to diarrhea
D. Alteration in nutrition, less than body requirements, related to decreased oral intake
Answer: B
B. Fluid volume deficit related to excessive losses and inadequate intake
Rationale: In infants, dehydration develops rapidly because:
They have higher metabolic rates
They have higher total body water
They cannot communicate thirst
They rely entirely on caregivers for intake
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 nurse is assessing a 4-year-old child diagnosed with strabismus. Which interventions should the nurse anticipate to help prevent amblyopia?
Select all that apply.
A. Patch the stronger eye
B. Administer antibiotic eye drops daily
C. Encourage use of corrective eyeglasses
D. Surgical correction of eye muscles
E. Encourage the child to alternate which eye is used for vision
Correct Answers: A, C, D
A. Patch the stronger eye
C. Encourage use of corrective eyeglasses
D. Surgical correction of eye muscles
Rationale:
A. Correct – Patching the stronger eye forces the weaker eye to work and prevents amblyopia.
B. Incorrect – Antibiotics are used for infection, not strabismus.
C. Correct – Glasses can help correct refractive errors contributing to misalignment.
D. Correct – Eye muscle surgery may be required if conservative treatments fail.
E. Incorrect – Vision is not voluntarily alternated; the brain suppresses the weaker eye.
A nurse is reviewing the echocardiogram report of a child diagnosed with Tetralogy of Fallot. Which of the following findings are components of this condition?
Select all that apply.
A. Ventricular septal defect
B. Pulmonary stenosis
C. Right ventricular hypertrophy
D. Overriding aorta
E. Atrial septal defect
Answer: A, B, C, D
Rationale: Tetralogy of Fallot has four classic structural abnormalities:
A. Ventricular septal defect
B. Pulmonary stenosis
C. Right ventricular hypertrophy
D. Overriding aorta
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
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.
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.