Nur 254 Exam 4 - 2026/2027 Edition – Actual
Questions with 100% Verified Correct
Answers -Galen
50 Questions with Step-by-Step Answers | 100% Verified | A+ Graded Review
INTRODUCTION :
This Nur 254 Exam 4 Version A comprehensively covers essential pediatric
nursing topics including ADHD, seizures, cerebral palsy, autism, increased ICP,
head injury, meningitis, Reye's syndrome, Down syndrome, Wilms tumor, sickle
cell crisis, osteosarcoma, leukemia, anemia, diabetes, fractures, compartment
syndrome, PKU, hypothyroidism, atopic dermatitis, and end-of-life care, with
verified Green answers and blue rationales for mastery and confident exam
preparation success.
1. The nurse is assessing a school-age child with attention-deficit/hyperactivity
disorder (ADHD) at school. Which of the following behaviors should the nurse
include in the assessment?
a. Completes projects quickly.
b. Prefers detailed tasks.
c. Refrains from volunteering.
d. Grabs items from others without thinking.
Rationale: ADHD hallmark is impulsivity, hyperactivity, inattention. Grabbing items without
thinking = impulsive behavior. Completing quickly and preferring detailed tasks are opposite
of ADHD manifestations.
2. The nurse is caring for an infant who is having an active seizure. Which of the
following actions should the nurse perform when caring for the infant during a
seizure?
a. Place the infant in the prone position inside the crib.
b. Suction any secretions out of the infant's mouth.
c. Swaddle the infant to keep them warm and safe.
d. Remove any items out of the crib that can harm the infant.
, Rationale: During seizure, do NOT restrain, do NOT place prone, do NOT suction during
active seizure. Protect from injury by removing harmful objects, maintain side-lying position,
ensure airway after seizure.
3. The nurse is screening infants for signs of cerebral palsy. Which findings from
the box below should the nurse recognize as early signs of cerebral palsy?
1. Poor head control/lag after 1 month.
2. Feeding difficulties.
3. Failure to smile by 2 months.
4. Persistent Moro reflex
5. Rigid arms or legs
a. 1, 2, 3
b. 3, 4, 5
c. 1, 2, 4, 5
d. 1, 2, 3, 4, 5
Rationale: Early CP: poor head control, feeding difficulty due to poor coordination,
persistence of primitive reflexes like Moro beyond 4-6 months, and hypertonia/rigidity. Failure
to smile is general developmental delay, less specific. Best cluster is 1,2,4,5.
4. The nurse is admitting a toddler who is being hospitalized following a near-
drowning accident/submersion injury. The toddler is spontaneously breathing but
is unconscious. Which of the following actions should the nurse perform first?
a. Administer oxygen via face mask.
b. Implement seizure precautions.
c. Notify spiritual advisor of parents’ choice.
d. Obtain arterial blood gases (ABGs).
Rationale: ABCs priority. Unconscious post-submersion child at high risk for hypoxia,
aspiration, pulmonary edema. Oxygen first, then ABGs, neuro assessment.
5. The nurse is assessing a 6-year-old child for manifestations of autism spectrum
disorder (ASD). Which of the following manifestations should the nurse expect to
observe in this child?
a. Continuous eye contact.
b. Increased imitation of others.
c. Interest in various activities.
d. Verbal development delay.
Rationale: ASD: poor eye contact, lack of imitation, restricted repetitive interests, language
delay, echolalia, difficulty with social communication.
, 6. The nurse is caring for a child who has increased intracranial pressure (ICP)
and is in stable condition. Which of the following interventions should the nurse
implement to decrease ICP in the child?
a. Increase the number of visitors inside the child's room.
b. Administer hypotonic intravenous (IV) fluids.
c. Keep the child positioned midline on the bed.
d. Administer opioids for pain control.
Rationale: Keep head midline neutral, HOB elevated 15-30° to promote venous drainage.
Avoid stimuli, avoid hypotonic fluids that worsen cerebral edema, avoid hip flexion.
7. The nurse is caring for a child who had a ventricular shunt placement 24 hours
ago. The child is sitting up in bed crying and has vomited a small amount on the
bed linens. Which of the following actions should the nurse take first?
a. Perform a neurologic assessment.
b. Obtain a complete metabolic panel (CMP) specimen.
c. Comfort the child while the linens are changed.
d. Inspect the incision site for infection.
Rationale: Vomiting, crying, irritability 24h post VP shunt suggests increased ICP / shunt
malfunction. First is rapid neuro assessment: LOC, pupils, vitals, bulging fontanel.
8. The nurse is caring for a child who is hospitalized for 24-hour observation
following a head injury. Which of the following actions by the nurse is the
priority?
a. Assess for neck stiffness.
b. Lower the television sound.
c. Checking pupil reaction every 4 hours.
d. Restrict visitation to 1 person at a time.
Rationale: Priority is ongoing neuro assessment including pupil reaction to light to detect ICP
changes. Though ideally more frequent than q4h, neuro checks take precedence over
comfort measures.
9. The nurse is assessing a child who is in a coma and notes decorticate
posturing. Which of the following findings should the nurse expect the child to
demonstrate?
Questions with 100% Verified Correct
Answers -Galen
50 Questions with Step-by-Step Answers | 100% Verified | A+ Graded Review
INTRODUCTION :
This Nur 254 Exam 4 Version A comprehensively covers essential pediatric
nursing topics including ADHD, seizures, cerebral palsy, autism, increased ICP,
head injury, meningitis, Reye's syndrome, Down syndrome, Wilms tumor, sickle
cell crisis, osteosarcoma, leukemia, anemia, diabetes, fractures, compartment
syndrome, PKU, hypothyroidism, atopic dermatitis, and end-of-life care, with
verified Green answers and blue rationales for mastery and confident exam
preparation success.
1. The nurse is assessing a school-age child with attention-deficit/hyperactivity
disorder (ADHD) at school. Which of the following behaviors should the nurse
include in the assessment?
a. Completes projects quickly.
b. Prefers detailed tasks.
c. Refrains from volunteering.
d. Grabs items from others without thinking.
Rationale: ADHD hallmark is impulsivity, hyperactivity, inattention. Grabbing items without
thinking = impulsive behavior. Completing quickly and preferring detailed tasks are opposite
of ADHD manifestations.
2. The nurse is caring for an infant who is having an active seizure. Which of the
following actions should the nurse perform when caring for the infant during a
seizure?
a. Place the infant in the prone position inside the crib.
b. Suction any secretions out of the infant's mouth.
c. Swaddle the infant to keep them warm and safe.
d. Remove any items out of the crib that can harm the infant.
, Rationale: During seizure, do NOT restrain, do NOT place prone, do NOT suction during
active seizure. Protect from injury by removing harmful objects, maintain side-lying position,
ensure airway after seizure.
3. The nurse is screening infants for signs of cerebral palsy. Which findings from
the box below should the nurse recognize as early signs of cerebral palsy?
1. Poor head control/lag after 1 month.
2. Feeding difficulties.
3. Failure to smile by 2 months.
4. Persistent Moro reflex
5. Rigid arms or legs
a. 1, 2, 3
b. 3, 4, 5
c. 1, 2, 4, 5
d. 1, 2, 3, 4, 5
Rationale: Early CP: poor head control, feeding difficulty due to poor coordination,
persistence of primitive reflexes like Moro beyond 4-6 months, and hypertonia/rigidity. Failure
to smile is general developmental delay, less specific. Best cluster is 1,2,4,5.
4. The nurse is admitting a toddler who is being hospitalized following a near-
drowning accident/submersion injury. The toddler is spontaneously breathing but
is unconscious. Which of the following actions should the nurse perform first?
a. Administer oxygen via face mask.
b. Implement seizure precautions.
c. Notify spiritual advisor of parents’ choice.
d. Obtain arterial blood gases (ABGs).
Rationale: ABCs priority. Unconscious post-submersion child at high risk for hypoxia,
aspiration, pulmonary edema. Oxygen first, then ABGs, neuro assessment.
5. The nurse is assessing a 6-year-old child for manifestations of autism spectrum
disorder (ASD). Which of the following manifestations should the nurse expect to
observe in this child?
a. Continuous eye contact.
b. Increased imitation of others.
c. Interest in various activities.
d. Verbal development delay.
Rationale: ASD: poor eye contact, lack of imitation, restricted repetitive interests, language
delay, echolalia, difficulty with social communication.
, 6. The nurse is caring for a child who has increased intracranial pressure (ICP)
and is in stable condition. Which of the following interventions should the nurse
implement to decrease ICP in the child?
a. Increase the number of visitors inside the child's room.
b. Administer hypotonic intravenous (IV) fluids.
c. Keep the child positioned midline on the bed.
d. Administer opioids for pain control.
Rationale: Keep head midline neutral, HOB elevated 15-30° to promote venous drainage.
Avoid stimuli, avoid hypotonic fluids that worsen cerebral edema, avoid hip flexion.
7. The nurse is caring for a child who had a ventricular shunt placement 24 hours
ago. The child is sitting up in bed crying and has vomited a small amount on the
bed linens. Which of the following actions should the nurse take first?
a. Perform a neurologic assessment.
b. Obtain a complete metabolic panel (CMP) specimen.
c. Comfort the child while the linens are changed.
d. Inspect the incision site for infection.
Rationale: Vomiting, crying, irritability 24h post VP shunt suggests increased ICP / shunt
malfunction. First is rapid neuro assessment: LOC, pupils, vitals, bulging fontanel.
8. The nurse is caring for a child who is hospitalized for 24-hour observation
following a head injury. Which of the following actions by the nurse is the
priority?
a. Assess for neck stiffness.
b. Lower the television sound.
c. Checking pupil reaction every 4 hours.
d. Restrict visitation to 1 person at a time.
Rationale: Priority is ongoing neuro assessment including pupil reaction to light to detect ICP
changes. Though ideally more frequent than q4h, neuro checks take precedence over
comfort measures.
9. The nurse is assessing a child who is in a coma and notes decorticate
posturing. Which of the following findings should the nurse expect the child to
demonstrate?
