NSG434 Exam 4 Actual Exam Style V2 |
NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 4-year-old child is brought to the emergency department with a high fever, muffled
voice, and drooling. The nurse suspects epiglottitis. Which action is the nurse’s priority?
A. Keep the child calm and notify the provider to prepare for intubation.
B. Obtain a throat culture and start intravenous antibiotics immediately.
C. Inspect the throat using a tongue depressor to confirm the diagnosis.
D. Place the child in a supine position to facilitate breathing.
Answer: A
Rationale: Epiglottitis is a medical emergency that can lead to sudden and complete
airway obstruction. The nurse must avoid any invasive procedures like throat inspection
that could trigger a laryngospasm. The priority is to maintain a patent airway by keeping
the child calm and preparing for emergency airway management.
2. When troubleshooting a sudden drop in oxygen saturation for a child on a mechanical
ventilator, the nurse uses the DOPE mnemonic. What does the ‘D’ in DOPE stand for?
A. Decreased lung compliance
B. Displaced tube
C. Diaphragmatic fatigue
,D. Drug toxicity
Answer: B
Rationale: The DOPE mnemonic is a systematic way to troubleshoot problems in a
ventilated patient. It stands for Displacement, Obstruction, Pneumothorax, and Equipment
failure. Checking for tube displacement is the first step in identifying why the patient’s
status has deteriorated.
3. A 2-year-old is admitted with respiratory syncytial virus (RSV) bronchiolitis. What type of
isolation precautions should the nurse implement?
A. Standard and Airborne precautions
B. Standard, Contact, and Droplet precautions
C. Standard and Droplet precautions
D. Standard and Contact precautions
Answer: B
Rationale: RSV is primarily transmitted through direct contact with respiratory secretions
and can also be spread via large droplets. Therefore, the nurse must implement both
contact and droplet precautions to prevent nosocomial transmission. Hand hygiene and
appropriate personal protective equipment are essential components of these precautions.
, 4. An adolescent patient is being treated for major depressive disorder and has just started
taking a Selective Serotonin Reuptake Inhibitor (SSRI). What is the most important teaching
point for the family?
A. The medication will show full therapeutic effects within 24 hours.
B. Stop the medication immediately if the patient feels slightly nauseous.
C. The patient may experience a sudden increase in energy and suicidal ideation.
D. There are no dietary restrictions while taking this class of medication.
Answer: C
Rationale: SSRIs can sometimes cause a paradoxical increase in energy before the mood
fully improves, which may lead to a higher risk of suicide in children and adolescents.
Families must be educated to monitor the patient closely for changes in behavior or
expressed suicidal thoughts. This ‘black box warning’ is a critical safety consideration
during the initial weeks of therapy.
5. A 10-year-old child is admitted with suspected bacterial meningitis. Which clinical finding
should the nurse expect to observe during the assessment?
A. Negative Kernig sign
B. Hypothermia and bradycardia
C. Nuchal rigidity and headache
D. Sunken fontanels and clear CSF
NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 4-year-old child is brought to the emergency department with a high fever, muffled
voice, and drooling. The nurse suspects epiglottitis. Which action is the nurse’s priority?
A. Keep the child calm and notify the provider to prepare for intubation.
B. Obtain a throat culture and start intravenous antibiotics immediately.
C. Inspect the throat using a tongue depressor to confirm the diagnosis.
D. Place the child in a supine position to facilitate breathing.
Answer: A
Rationale: Epiglottitis is a medical emergency that can lead to sudden and complete
airway obstruction. The nurse must avoid any invasive procedures like throat inspection
that could trigger a laryngospasm. The priority is to maintain a patent airway by keeping
the child calm and preparing for emergency airway management.
2. When troubleshooting a sudden drop in oxygen saturation for a child on a mechanical
ventilator, the nurse uses the DOPE mnemonic. What does the ‘D’ in DOPE stand for?
A. Decreased lung compliance
B. Displaced tube
C. Diaphragmatic fatigue
,D. Drug toxicity
Answer: B
Rationale: The DOPE mnemonic is a systematic way to troubleshoot problems in a
ventilated patient. It stands for Displacement, Obstruction, Pneumothorax, and Equipment
failure. Checking for tube displacement is the first step in identifying why the patient’s
status has deteriorated.
3. A 2-year-old is admitted with respiratory syncytial virus (RSV) bronchiolitis. What type of
isolation precautions should the nurse implement?
A. Standard and Airborne precautions
B. Standard, Contact, and Droplet precautions
C. Standard and Droplet precautions
D. Standard and Contact precautions
Answer: B
Rationale: RSV is primarily transmitted through direct contact with respiratory secretions
and can also be spread via large droplets. Therefore, the nurse must implement both
contact and droplet precautions to prevent nosocomial transmission. Hand hygiene and
appropriate personal protective equipment are essential components of these precautions.
, 4. An adolescent patient is being treated for major depressive disorder and has just started
taking a Selective Serotonin Reuptake Inhibitor (SSRI). What is the most important teaching
point for the family?
A. The medication will show full therapeutic effects within 24 hours.
B. Stop the medication immediately if the patient feels slightly nauseous.
C. The patient may experience a sudden increase in energy and suicidal ideation.
D. There are no dietary restrictions while taking this class of medication.
Answer: C
Rationale: SSRIs can sometimes cause a paradoxical increase in energy before the mood
fully improves, which may lead to a higher risk of suicide in children and adolescents.
Families must be educated to monitor the patient closely for changes in behavior or
expressed suicidal thoughts. This ‘black box warning’ is a critical safety consideration
during the initial weeks of therapy.
5. A 10-year-old child is admitted with suspected bacterial meningitis. Which clinical finding
should the nurse expect to observe during the assessment?
A. Negative Kernig sign
B. Hypothermia and bradycardia
C. Nuchal rigidity and headache
D. Sunken fontanels and clear CSF
