CCRN Pediatric Exam Practice 50 Questions,
Answers, and Rationale from AACN Practice
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Terms in this set (57)
Answer: D) Explain to the sibling that thoughts and
To promote effective
wishes did not cause the infant's death: At age 6,
grieving in a 6-year-old
children may take words literally and because of
sibling following the
their egocentrism, they believe that thoughts are all-
death of an infant, the
powerful. They may truly believe they caused the
nurse should:
death of their sibling. A simple, honest explanation
A) Recommend that the
of why the sibling died is indicated. This intervention
sibling not attend the
is consistent with Caring Processes.
infant's memorial service
A) Recommend that the sibling not attend the
B) Encourage the parents
infant's memorial service: This intervention is not a
to minimize their
solution to the problem and will not promote
expression of grief with
effective grieving for the sibling. It is not consistent
the sibling
with Caring Processes.
C) Explain to the sibling
B) Encourage the parents to minimize their
that the infant went to
expression of grief with the sibling: This intervention
heaven
will lead to ineffective grieving for the sibling and is
D) Explain to the sibling
not consistent with Caring Processes
that thoughts and wishes
C) Explain to the sibling that the infant went to
did not cause the infant's
heaven: This intervention will not address the
death
sibling's problem
, Answer: B) The patient having a CT scan followed by
possible shunt revision: This patient is demonstrating
A 5-year-old with a signs of increased intracranial pressure. The most
history of congenital likely etiology is malfunction of the VP shunt as a
hydrocephalus and VP result of blockage or disconnection, which is
shunt placement at four particularly likely over time as the child grows. The
weeks of age is admitted definitive diagnosis is made by a CT scan and a
with increased shunt series. Surgical intervention for a shunt
somnolence, decreased revision would be indicated.
appetite, and increased A) The physician ordering lumbar puncture and
complaints of headache. blood and urine cultures: These interventions will
This morning the child not address the most likely primary problem, which
vomited twice. The nurse is suspected VP shunt malfunction. Additionally,
should anticipate: lumbar puncture is contraindicated in the presence
A) The physician ordering of increased intracranial pressure, because
lumbar puncture and downward herniation of the brainstem can occur.
blood and urine cultures C) Administering mannitol or hypertonic saline:
B) the patient having a CT These medication are indicated for the medical
scan followed by management of increased intracranial pressure, of
possible shunt revision which this patient has symptoms. However, they will
C) Administering not address the most likely primary problem, which
mannitol or hypertonic is suspected VP shunt malfunction.
saline D) Administering phenytoin (Dilantin) or
D) Administering fosphenytoin (Cerebyx): These medications are
phenytoin (Dilantin) or indicated for seizure management and would not
fosphenytoin (Cerebyx) address the patient's most likely primary problem,
which is suspected increased intracranial pressure
as a result of VP shunt malfunction
, Answer: C) Splenic laceration: Kehr's sign, which is
referred pain to the left shoulder during
compression of the left upper abdominal quadrant,
An adolescent trauma is an indication of splenic injury. Additional
patient is complaining of symptoms include tachycardia, hypotension, and
left upper quadrant leukocytosis
abdominal pain radiating A) Small bowel injury: Signs of small bowel injury
to the left shoulder. may include progressive abdominal distension, not
Blood pressure has referred left shoulder pain.
dropped to 80/50. Which B) Cardiac Contusion: Signs of cardiac contusion
condition is most likely? include chest pain, arrhythmias, and other indicators
A) Small Bowel Injury of myocardial dysfunction, such as elevated cardiac
B) Cardiac Contusion isoenzymes. Upper quadrant abdominal pain with
C) Splenic Laceration radiation to the left shoulder is not consistent with a
D) Pulmonary Embolism cardiac contusion
D) Pulmonary Embolism: Symptoms of pulmonary
embolism include chest pain and dyspnea on
exertion, not left shoulder pain
Answer: D) Airway Patency: The first priority after
admitting an infant with encephalitis is to assess the
patient's ability to maintain airway patency. Such
patients can develop rapid neurologic deterioration,
and the nurse must be prepared to support the
airway, oxygenation, and ventilation as needed.
An infant has been
A) Pupillary Response: The infant with encephalitis
admitted with
should be monitored for changes in neurologic
encephalitis. The nurse
status, including pupillary response. However,
should first assess the
assessing the patient;s ability to maintain airway
patient's:
patency is the first priority.
A) Pupillary response
B) Blood Glucose Level: The infant with encephalitis
B) Blood glucose level
will need blood glucose levels monitored,
C) Level of
especially if unable to maintain adequate oral intake.
consciousness
However, assessing the patient's ability to maintain
D) Airway Patency
airway patency is the first priority.
C) Level of consciousness: The infant with
encephalitis should be monitored for changes in
neurologic status, including assessment of the level
of consciousness. However, assessing the patient's
ability to maintain airway patency is the first priority.
, Answer: C) Confusion: The patient with asphyxia
from smoke inhalation will experience cerebral
hypoxemia and demonstrate symptoms of
neurologic dysfunction, including confusion
The pediatric patient with A) Tachypnea: While the patient with smoke
suspected asphyxia from inhalation may experience tachypnea as a result of
smoke inhalation will damage to the lung parenchyma, this symptoms is
typically present with: not specific to asphyxia
A) Tachypnea B) Cyanosis: While the patient with smoke inhalation
B) Cyanosis may experience cyanosis as a result of damage to
C) Confusion the lung parenchyma, this symptoms is not specific
D) Hypotension to asphyxia
D) Hypotension: While the patient with smoke
inhalation and a burn injury may demonstrate
hypotension from fluid shifts, this symptoms is not
specific to asphyxia
Answers, and Rationale from AACN Practice
Book Recently Updated Solution
Save
Terms in this set (57)
Answer: D) Explain to the sibling that thoughts and
To promote effective
wishes did not cause the infant's death: At age 6,
grieving in a 6-year-old
children may take words literally and because of
sibling following the
their egocentrism, they believe that thoughts are all-
death of an infant, the
powerful. They may truly believe they caused the
nurse should:
death of their sibling. A simple, honest explanation
A) Recommend that the
of why the sibling died is indicated. This intervention
sibling not attend the
is consistent with Caring Processes.
infant's memorial service
A) Recommend that the sibling not attend the
B) Encourage the parents
infant's memorial service: This intervention is not a
to minimize their
solution to the problem and will not promote
expression of grief with
effective grieving for the sibling. It is not consistent
the sibling
with Caring Processes.
C) Explain to the sibling
B) Encourage the parents to minimize their
that the infant went to
expression of grief with the sibling: This intervention
heaven
will lead to ineffective grieving for the sibling and is
D) Explain to the sibling
not consistent with Caring Processes
that thoughts and wishes
C) Explain to the sibling that the infant went to
did not cause the infant's
heaven: This intervention will not address the
death
sibling's problem
, Answer: B) The patient having a CT scan followed by
possible shunt revision: This patient is demonstrating
A 5-year-old with a signs of increased intracranial pressure. The most
history of congenital likely etiology is malfunction of the VP shunt as a
hydrocephalus and VP result of blockage or disconnection, which is
shunt placement at four particularly likely over time as the child grows. The
weeks of age is admitted definitive diagnosis is made by a CT scan and a
with increased shunt series. Surgical intervention for a shunt
somnolence, decreased revision would be indicated.
appetite, and increased A) The physician ordering lumbar puncture and
complaints of headache. blood and urine cultures: These interventions will
This morning the child not address the most likely primary problem, which
vomited twice. The nurse is suspected VP shunt malfunction. Additionally,
should anticipate: lumbar puncture is contraindicated in the presence
A) The physician ordering of increased intracranial pressure, because
lumbar puncture and downward herniation of the brainstem can occur.
blood and urine cultures C) Administering mannitol or hypertonic saline:
B) the patient having a CT These medication are indicated for the medical
scan followed by management of increased intracranial pressure, of
possible shunt revision which this patient has symptoms. However, they will
C) Administering not address the most likely primary problem, which
mannitol or hypertonic is suspected VP shunt malfunction.
saline D) Administering phenytoin (Dilantin) or
D) Administering fosphenytoin (Cerebyx): These medications are
phenytoin (Dilantin) or indicated for seizure management and would not
fosphenytoin (Cerebyx) address the patient's most likely primary problem,
which is suspected increased intracranial pressure
as a result of VP shunt malfunction
, Answer: C) Splenic laceration: Kehr's sign, which is
referred pain to the left shoulder during
compression of the left upper abdominal quadrant,
An adolescent trauma is an indication of splenic injury. Additional
patient is complaining of symptoms include tachycardia, hypotension, and
left upper quadrant leukocytosis
abdominal pain radiating A) Small bowel injury: Signs of small bowel injury
to the left shoulder. may include progressive abdominal distension, not
Blood pressure has referred left shoulder pain.
dropped to 80/50. Which B) Cardiac Contusion: Signs of cardiac contusion
condition is most likely? include chest pain, arrhythmias, and other indicators
A) Small Bowel Injury of myocardial dysfunction, such as elevated cardiac
B) Cardiac Contusion isoenzymes. Upper quadrant abdominal pain with
C) Splenic Laceration radiation to the left shoulder is not consistent with a
D) Pulmonary Embolism cardiac contusion
D) Pulmonary Embolism: Symptoms of pulmonary
embolism include chest pain and dyspnea on
exertion, not left shoulder pain
Answer: D) Airway Patency: The first priority after
admitting an infant with encephalitis is to assess the
patient's ability to maintain airway patency. Such
patients can develop rapid neurologic deterioration,
and the nurse must be prepared to support the
airway, oxygenation, and ventilation as needed.
An infant has been
A) Pupillary Response: The infant with encephalitis
admitted with
should be monitored for changes in neurologic
encephalitis. The nurse
status, including pupillary response. However,
should first assess the
assessing the patient;s ability to maintain airway
patient's:
patency is the first priority.
A) Pupillary response
B) Blood Glucose Level: The infant with encephalitis
B) Blood glucose level
will need blood glucose levels monitored,
C) Level of
especially if unable to maintain adequate oral intake.
consciousness
However, assessing the patient's ability to maintain
D) Airway Patency
airway patency is the first priority.
C) Level of consciousness: The infant with
encephalitis should be monitored for changes in
neurologic status, including assessment of the level
of consciousness. However, assessing the patient's
ability to maintain airway patency is the first priority.
, Answer: C) Confusion: The patient with asphyxia
from smoke inhalation will experience cerebral
hypoxemia and demonstrate symptoms of
neurologic dysfunction, including confusion
The pediatric patient with A) Tachypnea: While the patient with smoke
suspected asphyxia from inhalation may experience tachypnea as a result of
smoke inhalation will damage to the lung parenchyma, this symptoms is
typically present with: not specific to asphyxia
A) Tachypnea B) Cyanosis: While the patient with smoke inhalation
B) Cyanosis may experience cyanosis as a result of damage to
C) Confusion the lung parenchyma, this symptoms is not specific
D) Hypotension to asphyxia
D) Hypotension: While the patient with smoke
inhalation and a burn injury may demonstrate
hypotension from fluid shifts, this symptoms is not
specific to asphyxia
