NR 110.646 Exam 3 V2 | NR 110.646
Advanced Pediatric Acute Care Topics |
Actual Q&A with Rationale (NR110646
Exam 3) | Johns Hopkins University
1. A 6-year-old child presents to the emergency department with suspected septic shock.
Which of the following clinical findings is most indicative of the compensated stage of shock
in this pediatric patient?
A. Hypotension for age
B. Tachycardia and delayed capillary refill
C. Narrowing pulse pressure
D. Altered mental status
Answer: B
Rationale: In pediatric patients, compensated shock is characterized by the body’s ability
to maintain blood pressure through compensatory mechanisms like tachycardia and
peripheral vasoconstriction. Tachycardia is often the earliest sign of cardiovascular
compromise as the heart attempts to maintain cardiac output. Recognition of these subtle
signs is vital because children can maintain a normal blood pressure until they have lost up
to 25-30% of their circulating volume.
,2. A 10-year-old is admitted with partial-thickness burns covering 30% of their total body
surface area (TBSA). According to the modified Parkland formula for pediatrics, what is the
recommended fluid resuscitation volume for the first 24 hours?
A. 2 mL/kg/% TBSA
B. 3 mL/kg/% TBSA
C. 3-4 mL/kg/% TBSA plus maintenance fluids
D. 5 mL/kg/% TBSA
Answer: C
Rationale: Pediatric burn resuscitation requires a combination of replacement for the burn
injury and standard maintenance fluids to account for the child’s higher metabolic rate. The
modified Parkland formula typically utilizes 3 to 4 mL of Lactated Ringer’s per kilogram
per percentage of TBSA burned. Half of this calculated volume is administered over the first
8 hours following the injury, with the remainder given over the subsequent 16 hours.
3. A patient with Diabetic Ketoacidosis (DKA) is being managed in the PICU. The nurse
practitioner notes a sudden decrease in heart rate and an increase in blood pressure. Which
intervention should be prioritized immediately?
A. Increase the insulin infusion rate
B. Perform a stat CT scan of the head
C. Administer IV Mannitol or Hypertonic Saline
D. Bolus 20 mL/kg of Normal Saline
,Answer: C
Rationale: Cushing’s triad, consisting of bradycardia, hypertension, and irregular
respirations, is a late sign of increased intracranial pressure and impending cerebral edema
in DKA. Cerebral edema is a significant cause of mortality in pediatric DKA and requires
immediate osmotic therapy to reduce brain swelling. The nurse practitioner must act
promptly to administer Mannitol or hypertonic saline before confirming the diagnosis with
imaging to prevent herniation.
4. A 12-year-old child is brought to the trauma bay after a high-velocity motor vehicle
collision. The patient complains of left shoulder pain (Kehr’s sign) despite no obvious injury to
the shoulder. This finding is most suggestive of injury to which organ?
A. Spleen
B. Liver
C. Pancreas
D. Left Kidney
Answer: A
Rationale: Kehr’s sign refers to referred pain in the left shoulder caused by diaphragmatic
irritation from blood in the peritoneal cavity. This is a classic indicator of splenic rupture or
subcapsular hematoma following blunt abdominal trauma. Management usually prioritizes
non-operative care in hemodynamically stable pediatric patients, but close monitoring in
the PICU is mandatory.
, 5. A 14-year-old adolescent is suspected of an acute acetaminophen overdose. At what point
following ingestion should the serum acetaminophen level be drawn to accurately use the
Rumack-Matthew Nomogram?
A. 4 hours post-ingestion
B. 2 hours post-ingestion
C. 1 hour post-ingestion
D. Immediately upon arrival
Answer: A
Rationale: The Rumack-Matthew Nomogram is designed to predict the risk of
hepatotoxicity based on a single serum acetaminophen level drawn at least 4 hours after an
acute ingestion. Levels drawn earlier than 4 hours may not reflect the peak concentration
and cannot be reliably plotted on the nomogram. If the ingestion time is unknown or the
level is above the treatment line, N-acetylcysteine therapy should be initiated immediately.
6. A toddler presents with bloody diarrhea, oliguria, and irritability. Laboratory results show
fragmented red blood cells (schistocytes), a low platelet count, and an elevated creatinine.
Which diagnosis is most likely?
A. Disseminated Intravascular Coagulation (DIC)
B. Hemolytic Uremic Syndrome (HUS)
C. Immune Thrombocytopenic Purpura (ITP)
D. Post-streptococcal Glomerulonephritis
Advanced Pediatric Acute Care Topics |
Actual Q&A with Rationale (NR110646
Exam 3) | Johns Hopkins University
1. A 6-year-old child presents to the emergency department with suspected septic shock.
Which of the following clinical findings is most indicative of the compensated stage of shock
in this pediatric patient?
A. Hypotension for age
B. Tachycardia and delayed capillary refill
C. Narrowing pulse pressure
D. Altered mental status
Answer: B
Rationale: In pediatric patients, compensated shock is characterized by the body’s ability
to maintain blood pressure through compensatory mechanisms like tachycardia and
peripheral vasoconstriction. Tachycardia is often the earliest sign of cardiovascular
compromise as the heart attempts to maintain cardiac output. Recognition of these subtle
signs is vital because children can maintain a normal blood pressure until they have lost up
to 25-30% of their circulating volume.
,2. A 10-year-old is admitted with partial-thickness burns covering 30% of their total body
surface area (TBSA). According to the modified Parkland formula for pediatrics, what is the
recommended fluid resuscitation volume for the first 24 hours?
A. 2 mL/kg/% TBSA
B. 3 mL/kg/% TBSA
C. 3-4 mL/kg/% TBSA plus maintenance fluids
D. 5 mL/kg/% TBSA
Answer: C
Rationale: Pediatric burn resuscitation requires a combination of replacement for the burn
injury and standard maintenance fluids to account for the child’s higher metabolic rate. The
modified Parkland formula typically utilizes 3 to 4 mL of Lactated Ringer’s per kilogram
per percentage of TBSA burned. Half of this calculated volume is administered over the first
8 hours following the injury, with the remainder given over the subsequent 16 hours.
3. A patient with Diabetic Ketoacidosis (DKA) is being managed in the PICU. The nurse
practitioner notes a sudden decrease in heart rate and an increase in blood pressure. Which
intervention should be prioritized immediately?
A. Increase the insulin infusion rate
B. Perform a stat CT scan of the head
C. Administer IV Mannitol or Hypertonic Saline
D. Bolus 20 mL/kg of Normal Saline
,Answer: C
Rationale: Cushing’s triad, consisting of bradycardia, hypertension, and irregular
respirations, is a late sign of increased intracranial pressure and impending cerebral edema
in DKA. Cerebral edema is a significant cause of mortality in pediatric DKA and requires
immediate osmotic therapy to reduce brain swelling. The nurse practitioner must act
promptly to administer Mannitol or hypertonic saline before confirming the diagnosis with
imaging to prevent herniation.
4. A 12-year-old child is brought to the trauma bay after a high-velocity motor vehicle
collision. The patient complains of left shoulder pain (Kehr’s sign) despite no obvious injury to
the shoulder. This finding is most suggestive of injury to which organ?
A. Spleen
B. Liver
C. Pancreas
D. Left Kidney
Answer: A
Rationale: Kehr’s sign refers to referred pain in the left shoulder caused by diaphragmatic
irritation from blood in the peritoneal cavity. This is a classic indicator of splenic rupture or
subcapsular hematoma following blunt abdominal trauma. Management usually prioritizes
non-operative care in hemodynamically stable pediatric patients, but close monitoring in
the PICU is mandatory.
, 5. A 14-year-old adolescent is suspected of an acute acetaminophen overdose. At what point
following ingestion should the serum acetaminophen level be drawn to accurately use the
Rumack-Matthew Nomogram?
A. 4 hours post-ingestion
B. 2 hours post-ingestion
C. 1 hour post-ingestion
D. Immediately upon arrival
Answer: A
Rationale: The Rumack-Matthew Nomogram is designed to predict the risk of
hepatotoxicity based on a single serum acetaminophen level drawn at least 4 hours after an
acute ingestion. Levels drawn earlier than 4 hours may not reflect the peak concentration
and cannot be reliably plotted on the nomogram. If the ingestion time is unknown or the
level is above the treatment line, N-acetylcysteine therapy should be initiated immediately.
6. A toddler presents with bloody diarrhea, oliguria, and irritability. Laboratory results show
fragmented red blood cells (schistocytes), a low platelet count, and an elevated creatinine.
Which diagnosis is most likely?
A. Disseminated Intravascular Coagulation (DIC)
B. Hemolytic Uremic Syndrome (HUS)
C. Immune Thrombocytopenic Purpura (ITP)
D. Post-streptococcal Glomerulonephritis
