Question 1: To promote effective grieving in a 6-year-old sibling following the death of an
infant, the nurse should:
A) Recommend that the sibling not attend the infant's memorial service
B) Encourage the parents to minimize their expression of grief with the sibling
C) Explain to the sibling that the infant went to heaven
D) Explain to the sibling that thoughts and wishes did not cause the infant's death
Correct Answer: D
Rationale: At age 6, children may take words literally and because of their egocentrism, they
believe that thoughts are all-powerful. They may truly believe they caused the death of their
sibling. A simple, honest explanation of why the sibling died is indicated. This intervention is
consistent with Caring Processes.
Question 2: A 5-year-old with a history of congenital hydrocephalus and VP shunt placement at
four weeks of age is admitted with increased somnolence, decreased appetite, and increased
complaints of headache. This morning the child vomited twice. The nurse should anticipate:
A) The physician ordering lumbar puncture and blood and urine cultures
B) The patient having a CT scan followed by possible shunt revision
C) Administering mannitol or hypertonic saline
D) Administering phenytoin (Dilantin) or fosphenytoin (Cerebyx)
Correct Answer: B
Rationale: This patient is demonstrating signs of increased intracranial pressure. The most likely
etiology is malfunction of the VP shunt as a result of blockage or disconnection, which is
particularly likely over time as the child grows. The definitive diagnosis is made by a CT scan
and a shunt series. Surgical intervention for a shunt revision would be indicated.
,Question 3: An adolescent trauma patient is complaining of left upper quadrant abdominal pain
radiating to the left shoulder. Blood pressure has dropped to 80/50. Which condition is most
likely?
A) Small Bowel Injury
B) Cardiac Contusion
C) Splenic Laceration
D) Pulmonary Embolism
Correct Answer: C
Rationale: Kehr's sign, which is referred pain to the left shoulder during compression of the left
upper abdominal quadrant, is an indication of splenic injury. Additional symptoms include
tachycardia, hypotension, and leukocytosis.
Question 4: An infant has been admitted with encephalitis. The nurse should first assess the
patient's:
A) Pupillary response
B) Blood glucose level
C) Level of consciousness
D) Airway Patency
Correct Answer: D
Rationale: 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.
Question 5: The pediatric patient with suspected asphyxia from smoke inhalation will typically
present with:
,A) Tachypnea
B) Cyanosis
C) Confusion
D) Hypotension
Correct Answer: C
Rationale: The patient with asphyxia from smoke inhalation will experience cerebral hypoxemia
and demonstrate symptoms of neurologic dysfunction, including confusion.
Question 6: An acutely ill infant is born to a Vietnamese family. The father asks few questions
about the infant's condition, and the mother asks none. Both parents appear to be proficient in
English. Which of the following is the most useful resource for a nurse caring for this infant?
A) Classes conducted by the primary nurse as the need arises
B) An interpreter who is proficient in the parents' language
C) Information about the cultural backgrounds represented in the community
D) Ongoing classes addressing the cultural needs of the community
Correct Answer: B
Rationale: This intervention is consistent with Response to Diversity. Providing an interpreter
may facilitate communication by the parents. Trained interpreters can improve outcomes by
helping to ensure effective communication between the healthcare team and the patient/family.
Question 7: A toddler with a history of unrepaired tetralogy of Fallot begins to cry while
intravenous access is attempted. Cyanosis, diaphoresis and tachypnea are noted. The most
appropriate nursing intervention would be to:
A) Administer a pre-medication before attempting the IV
B) Apply a face mask with oxygen
C) Transfuse red blood cells
D) Place the child in knee-chest position
, Correct Answer: D
Rationale: This maneuver aids blood return to the heart, thus alleviating cyanotic spells.
Question 8: A 1-month old infant presents with failure to thrive, frequent vomiting and
irritability since birth. The mother reports having another infant with the same symptoms who
died at 2 months of age. Which additional assessment finding would cause the nurse to suspect
an inborn error of metabolism?
A) Micrognathia
B) Microglossia
C) Petite Facial Features
D) Musty Urine Odor
Correct Answer: D
Rationale: This is a common indicator of a metabolic disorder, especially with a family history of
siblings dying early.
Question 9: A school-aged child with autism is admitted with a fractured femur and possible
head injury. Which of the following is important to promote adjustment to the hospital setting?
A) Assign a child life therapist per shift
B) Encourage lots of visitors
C) Adhere to a home schedule
D) Initiate new activities to keep the patient occupied
Correct Answer: C
Rationale: Autism spectrum disorders are a complex neurodevelopmental disorder of brain
function accompanied by a broad range and severity of intellectual and behavioral deficits,
which is best managed when adhering to a schedule and minimizing change, so adhering to a
home schedule is optimal. The schedule allows the child and family to optimally cope.
QUESTION: A patient who does not speak or understand English is admitted. Guidelines for
using a translator may include
infant, the nurse should:
A) Recommend that the sibling not attend the infant's memorial service
B) Encourage the parents to minimize their expression of grief with the sibling
C) Explain to the sibling that the infant went to heaven
D) Explain to the sibling that thoughts and wishes did not cause the infant's death
Correct Answer: D
Rationale: At age 6, children may take words literally and because of their egocentrism, they
believe that thoughts are all-powerful. They may truly believe they caused the death of their
sibling. A simple, honest explanation of why the sibling died is indicated. This intervention is
consistent with Caring Processes.
Question 2: A 5-year-old with a history of congenital hydrocephalus and VP shunt placement at
four weeks of age is admitted with increased somnolence, decreased appetite, and increased
complaints of headache. This morning the child vomited twice. The nurse should anticipate:
A) The physician ordering lumbar puncture and blood and urine cultures
B) The patient having a CT scan followed by possible shunt revision
C) Administering mannitol or hypertonic saline
D) Administering phenytoin (Dilantin) or fosphenytoin (Cerebyx)
Correct Answer: B
Rationale: This patient is demonstrating signs of increased intracranial pressure. The most likely
etiology is malfunction of the VP shunt as a result of blockage or disconnection, which is
particularly likely over time as the child grows. The definitive diagnosis is made by a CT scan
and a shunt series. Surgical intervention for a shunt revision would be indicated.
,Question 3: An adolescent trauma patient is complaining of left upper quadrant abdominal pain
radiating to the left shoulder. Blood pressure has dropped to 80/50. Which condition is most
likely?
A) Small Bowel Injury
B) Cardiac Contusion
C) Splenic Laceration
D) Pulmonary Embolism
Correct Answer: C
Rationale: Kehr's sign, which is referred pain to the left shoulder during compression of the left
upper abdominal quadrant, is an indication of splenic injury. Additional symptoms include
tachycardia, hypotension, and leukocytosis.
Question 4: An infant has been admitted with encephalitis. The nurse should first assess the
patient's:
A) Pupillary response
B) Blood glucose level
C) Level of consciousness
D) Airway Patency
Correct Answer: D
Rationale: 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.
Question 5: The pediatric patient with suspected asphyxia from smoke inhalation will typically
present with:
,A) Tachypnea
B) Cyanosis
C) Confusion
D) Hypotension
Correct Answer: C
Rationale: The patient with asphyxia from smoke inhalation will experience cerebral hypoxemia
and demonstrate symptoms of neurologic dysfunction, including confusion.
Question 6: An acutely ill infant is born to a Vietnamese family. The father asks few questions
about the infant's condition, and the mother asks none. Both parents appear to be proficient in
English. Which of the following is the most useful resource for a nurse caring for this infant?
A) Classes conducted by the primary nurse as the need arises
B) An interpreter who is proficient in the parents' language
C) Information about the cultural backgrounds represented in the community
D) Ongoing classes addressing the cultural needs of the community
Correct Answer: B
Rationale: This intervention is consistent with Response to Diversity. Providing an interpreter
may facilitate communication by the parents. Trained interpreters can improve outcomes by
helping to ensure effective communication between the healthcare team and the patient/family.
Question 7: A toddler with a history of unrepaired tetralogy of Fallot begins to cry while
intravenous access is attempted. Cyanosis, diaphoresis and tachypnea are noted. The most
appropriate nursing intervention would be to:
A) Administer a pre-medication before attempting the IV
B) Apply a face mask with oxygen
C) Transfuse red blood cells
D) Place the child in knee-chest position
, Correct Answer: D
Rationale: This maneuver aids blood return to the heart, thus alleviating cyanotic spells.
Question 8: A 1-month old infant presents with failure to thrive, frequent vomiting and
irritability since birth. The mother reports having another infant with the same symptoms who
died at 2 months of age. Which additional assessment finding would cause the nurse to suspect
an inborn error of metabolism?
A) Micrognathia
B) Microglossia
C) Petite Facial Features
D) Musty Urine Odor
Correct Answer: D
Rationale: This is a common indicator of a metabolic disorder, especially with a family history of
siblings dying early.
Question 9: A school-aged child with autism is admitted with a fractured femur and possible
head injury. Which of the following is important to promote adjustment to the hospital setting?
A) Assign a child life therapist per shift
B) Encourage lots of visitors
C) Adhere to a home schedule
D) Initiate new activities to keep the patient occupied
Correct Answer: C
Rationale: Autism spectrum disorders are a complex neurodevelopmental disorder of brain
function accompanied by a broad range and severity of intellectual and behavioral deficits,
which is best managed when adhering to a schedule and minimizing change, so adhering to a
home schedule is optimal. The schedule allows the child and family to optimally cope.
QUESTION: A patient who does not speak or understand English is admitted. Guidelines for
using a translator may include
