Answers
1. A preschooler has a small laceration that required 2 stitches. The
nurse covers the wound with a bandage knowing that it will
comfort the child to have it covered. What is the developmental
reason for this intervention?
A. Preschoolers are magical thinkers and imagine bandages keep
their insides from coming out
B. Preschoolers fear physical disability and believe a bandage
will prevent disability
C. Preschoolers explore orally and will likely chew or suck on the
stitches if left uncovered
D. Preschoolers are concerned with body image and don't want
to appear different than peers:
2. A 7-month-old presents to the emergency department with a
complaint of
fever. Assessment reveals a patent airway and slight cyanosis around
his lips and nail beds. He is alert and interactive. His vital signs are 38.5
°C (101.3 °F), HR 134, RR 32, BP 78/54 mm Hg, and SpO2 84%. The nurse
notes a healed surgical scar on his chest. Based on this assessment,
what is the nurse's priority?
A. Administer ibuprofen to treat the fever
B. Begin oxygen via a nonrebreather mask
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, C. Obtain a surgical history
D. Ask if the SpO2 is normal for him:
3. An 11-year-old presents to the emergency department with a
complaint of hitting his head while playing soccer. The nurse enters
the room and performs an across-the-room assessment. He is
staring at the wall. He has no increased work of breathing, and his
color is pink. Using the pediatric assessment triangle (PAT), what
classification will the nurse assign?
A. Well
B. Sick
C. Sicker
D. Sickest:
4. The pediatric prioritization process components include the
focused assess- ment, focused history, acuity rating decision and:
A. the pediatric assessment triangle (PAT).
B. developmental characteristics.
C. head-to-toe assessment.
D. life-saving interventions.:
5. A 2-year-old is brought to the emergency department by her
father when he found her face down in the pool. She remains
unresponsive and is breathing shallowly and slowly. Her color is
pale. What is the priority?
A. Administer 100% oxygen
B. Immobilize the cervical spine
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