HESI Case Study (Peds) Questions and
Answers
1. Meet the Clients: Casey and John Martin
Six-month-old Casey Martin and her 4-year-old brother, John Martin
sustain head injuries when the car driven by their mother is struck
head on at an intersection. Although Casey is in an infant seat, her head
is severely shaken. John unbuckles his car seat and his head strikes the
dash board with force.
The Martins are transported to the emergency department (ED) where
Mrs. Martin is treated and released. The children are triaged as needing
immediate intervention.:
2. The nurse recognizes that epidural hematomas have which
characteristic?: -
Rapid brain decompression
3. To prepare Casey's parents for her CT scan, which explanation by the
nurse is accurate?: A nurse from the ED will remain with Casey to monitor her constantly.
4. Which symptom is most characteristic of ICP in infants?: Separated cranial
sutures
1/
6
, 5. While conducting Casey's neurological assessment, the nurse notes
possible damage to cranial nerve III as evidenced by which of the
following symptoms?-
: Ptosis and dilated pupils
6. Which data should the nurse include in documenting Casey's ocular
findings?-
: Lid lag for both eyes and dilated pupils
7. While providing care for a child with an epidural hematoma, which
nursing interventions are most essential? (Select all that apply): -Frequent
neuro assessment
-Maintain the airway and monitor O2 sat
-Implement seizure precautions
-Monitor fluid status and osmolality
8. Which seizure precautions should the nurse plan to implement?: Padding the
side rails
9. Laboratory studies are prescribed for Casey. Which prescription
should the nurse question?: 24 hours urine collection
10. The mother asks the nurse why her child is having x-rays. Which
response is best for the nurse to provide?: It is important to assess for other injuries that
may have been sustained in the car accident.
2/
6
Answers
1. Meet the Clients: Casey and John Martin
Six-month-old Casey Martin and her 4-year-old brother, John Martin
sustain head injuries when the car driven by their mother is struck
head on at an intersection. Although Casey is in an infant seat, her head
is severely shaken. John unbuckles his car seat and his head strikes the
dash board with force.
The Martins are transported to the emergency department (ED) where
Mrs. Martin is treated and released. The children are triaged as needing
immediate intervention.:
2. The nurse recognizes that epidural hematomas have which
characteristic?: -
Rapid brain decompression
3. To prepare Casey's parents for her CT scan, which explanation by the
nurse is accurate?: A nurse from the ED will remain with Casey to monitor her constantly.
4. Which symptom is most characteristic of ICP in infants?: Separated cranial
sutures
1/
6
, 5. While conducting Casey's neurological assessment, the nurse notes
possible damage to cranial nerve III as evidenced by which of the
following symptoms?-
: Ptosis and dilated pupils
6. Which data should the nurse include in documenting Casey's ocular
findings?-
: Lid lag for both eyes and dilated pupils
7. While providing care for a child with an epidural hematoma, which
nursing interventions are most essential? (Select all that apply): -Frequent
neuro assessment
-Maintain the airway and monitor O2 sat
-Implement seizure precautions
-Monitor fluid status and osmolality
8. Which seizure precautions should the nurse plan to implement?: Padding the
side rails
9. Laboratory studies are prescribed for Casey. Which prescription
should the nurse question?: 24 hours urine collection
10. The mother asks the nurse why her child is having x-rays. Which
response is best for the nurse to provide?: It is important to assess for other injuries that
may have been sustained in the car accident.
2/
6
