ENPC 4TH EDITION PRACTICE TEST
Questions and Answers
1. 1. A preschooler has a small laceration that requires 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
Answer A.) Preschoolers are magical thinkers and imagine bandages keep their insides from
coming out.
Rationale: Preschoolers are magical and illogical thinkers and have difficulty distinguishing fantasy from
reality. They have misconceptions about illness, injury, and bodily functions. For example, they perceive that
if their skin is cut, they fear their insides will leak out. Covering a wound with a bandage helps them
with this fear.
,2. 2. 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 (101.3F), 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.
C.)Obtain a surgical history.
D.)Ask if the Spo2 is normal for him
Answer D.) Ask if the Spo2 is normal for him.
Rationale: Children with special healthcare needs may present differently than other children, but these
differences may be normal. The surgical scar on the chest is likely from a congenital heart defect repair.
The mother's chief complaint is the fever, not the color, pulse oximetry, or the respiratory distress. This
may be because these aspects of his assessment are normal. The intact mental status is also a sign that
he has adapted to lowers oxygen saturation's. The child's baseline must come from the caregiver before
any intervention.
3. 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
Rationale: In using the PAT, there is not a Well category. A child may
appear well and without disruption in any of the three components
of the PAT but is still designated sick. All pediatric patients
presenting to the emergency department are considered sick simply
based on the fact that the caregiver was concerned enough to bring
the child to the emergency department (p. 54).
B.)Sick
Rationale: If there is no disruption in any of the three components of
the PAT, a pediatric patient is considered sick. This child has an
abnormality in one of the three. He is staring at the wall, which is a
disruption in the general appearance component (p. 54).
C.)Sicker
Rationale: This child has a disruption in one of the three
components of the PAT. He is staring at the wall, which is a
disruption in the general appearance component. It may be that he
is anxious and fearful about the experience, but it could be a result
of the head injury. More assessment is required (p. 54).
D.)Sickest
Rationale: If there are disruptions in two or more of the three
components of the PAT, a pediatric patient is considered sickest
and needs immediate evaluation and intervention. This child has
an abnormality in one of the three components (p. 54)
Answer C.) Sicker
, Rationale: This child has a disruption in one of the three components of the PAT. He is staring at the
wall, which is a disruption in the general appearance component. It may be that he is anxious and fearful
about the experience, but it could be a result of the head injury. More assessment is required (p. 54).
4. 4. The pediatric prioritization process components include the
focused as- sessment, focused history, acuity rating decision and:
A.)the pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization
process include the pediatric assessment triangle (PAT), the focused
assessment (objective data), the focused history (subjective data),
and the assignment of the triage acuity rating. These
components ensure enough information is rapidly gath- ered and
used to provide appropriate care and timely interventions for
pedi- atric patients (p. 52).
B.)developmental characteristics.
Rationale: Developmental characteristics are incorporated into each
compo- nent of the pediatric prioritization
process but do not constitute a separate element (p. 52).
C.)head-to-toe assessment.
Rationale: The head-to-toe assessment is part of the focused
assessment but not a separate element (p. 52).
D.)life-saving interventions.
Rationale: Life-saving interventions should be performed at any point
through- out the prioritization process as
Questions and Answers
1. 1. A preschooler has a small laceration that requires 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
Answer A.) Preschoolers are magical thinkers and imagine bandages keep their insides from
coming out.
Rationale: Preschoolers are magical and illogical thinkers and have difficulty distinguishing fantasy from
reality. They have misconceptions about illness, injury, and bodily functions. For example, they perceive that
if their skin is cut, they fear their insides will leak out. Covering a wound with a bandage helps them
with this fear.
,2. 2. 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 (101.3F), 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.
C.)Obtain a surgical history.
D.)Ask if the Spo2 is normal for him
Answer D.) Ask if the Spo2 is normal for him.
Rationale: Children with special healthcare needs may present differently than other children, but these
differences may be normal. The surgical scar on the chest is likely from a congenital heart defect repair.
The mother's chief complaint is the fever, not the color, pulse oximetry, or the respiratory distress. This
may be because these aspects of his assessment are normal. The intact mental status is also a sign that
he has adapted to lowers oxygen saturation's. The child's baseline must come from the caregiver before
any intervention.
3. 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
Rationale: In using the PAT, there is not a Well category. A child may
appear well and without disruption in any of the three components
of the PAT but is still designated sick. All pediatric patients
presenting to the emergency department are considered sick simply
based on the fact that the caregiver was concerned enough to bring
the child to the emergency department (p. 54).
B.)Sick
Rationale: If there is no disruption in any of the three components of
the PAT, a pediatric patient is considered sick. This child has an
abnormality in one of the three. He is staring at the wall, which is a
disruption in the general appearance component (p. 54).
C.)Sicker
Rationale: This child has a disruption in one of the three
components of the PAT. He is staring at the wall, which is a
disruption in the general appearance component. It may be that he
is anxious and fearful about the experience, but it could be a result
of the head injury. More assessment is required (p. 54).
D.)Sickest
Rationale: If there are disruptions in two or more of the three
components of the PAT, a pediatric patient is considered sickest
and needs immediate evaluation and intervention. This child has
an abnormality in one of the three components (p. 54)
Answer C.) Sicker
, Rationale: This child has a disruption in one of the three components of the PAT. He is staring at the
wall, which is a disruption in the general appearance component. It may be that he is anxious and fearful
about the experience, but it could be a result of the head injury. More assessment is required (p. 54).
4. 4. The pediatric prioritization process components include the
focused as- sessment, focused history, acuity rating decision and:
A.)the pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization
process include the pediatric assessment triangle (PAT), the focused
assessment (objective data), the focused history (subjective data),
and the assignment of the triage acuity rating. These
components ensure enough information is rapidly gath- ered and
used to provide appropriate care and timely interventions for
pedi- atric patients (p. 52).
B.)developmental characteristics.
Rationale: Developmental characteristics are incorporated into each
compo- nent of the pediatric prioritization
process but do not constitute a separate element (p. 52).
C.)head-to-toe assessment.
Rationale: The head-to-toe assessment is part of the focused
assessment but not a separate element (p. 52).
D.)life-saving interventions.
Rationale: Life-saving interventions should be performed at any point
through- out the prioritization process as
