NR328/NR 328 Exam 4 V2 | Pediatric Nursing Q&A
with Rationale | Chamberlain University
1. A nurse is assessing a child with a suspected head injury. Which of the following is the
earliest sign of increased intracranial pressure (ICP)?
A. Level of consciousness changes
B. Fixed and dilated pupils
C. Bradycardia
D. Cheyne-Stokes respirations
Correct Answer: A
Explanation: A change in the level of consciousness (LOC) is the most sensitive and
earliest indicator of neurological deterioration and increased ICP. In children, this may
manifest as irritability, restlessness, or decreased responsiveness to parents. Late signs of
increased ICP include Cushing’s triad (bradycardia, hypertension, and irregular
respirations) and pupillary changes.
2. A child is admitted with a diagnosis of bacterial meningitis. Which of the following results
would the nurse expect to find in the cerebrospinal fluid (CSF) analysis?
A. Increased glucose and decreased protein
B. Decreased glucose and increased protein
C. Clear appearance with normal pressure
,D. Absence of white blood cells
Correct Answer: B
Explanation: In bacterial meningitis, the CSF typically shows a decrease in glucose because
the bacteria consume it as a nutrient source. Protein levels are elevated due to the
inflammatory process and the presence of bacterial waste. The CSF will also appear cloudy
or turbid, and the opening pressure is usually elevated during the lumbar puncture.
3. The nurse is caring for a 10-year-old child with Type 1 Diabetes Mellitus who is planning to
play soccer. Which instruction should the nurse provide?
A. Decrease fluid intake before and during the game.
B. Eat a carbohydrate snack 30 minutes before exercise.
C. Administer an extra dose of insulin before the match.
D. Skip the soccer game if blood glucose is 150 mg/dL.
Correct Answer: B
Explanation: Physical activity increases the uptake of glucose by the muscles, which can
lead to hypoglycemia in children with Type 1 Diabetes. To prevent this, the child should
consume a carbohydrate snack before participating in vigorous exercise. The child should
also monitor blood glucose levels more frequently and carry a fast-acting glucose source
during the activity.
,4. A toddler is brought to the emergency department with a 25% total body surface area
(TBSA) burn. What is the priority nursing intervention during the first 24 hours?
A. Applying topical antibiotic ointment
B. Planning for skin grafting
C. Debriding the burn wounds
D. Initiating fluid resuscitation
Correct Answer: D
Explanation: Fluid resuscitation is the critical priority during the emergent phase of burn
care to prevent hypovolemic shock. Large amounts of fluid shift from the intravascular
space to the interstitial space following major burns. The nurse must monitor urine output
and vital signs closely to ensure adequate tissue perfusion and organ function.
5. Which assessment finding should the nurse prioritize in a child who has a new fiberglass
cast on the right lower leg?
A. The child reports the cast feels heavy.
B. Capillary refill of 2 seconds in the right toes.
C. Presence of a ‘hot spot’ on the surface of the cast.
D. The child is unable to wiggle the toes on the right foot.
Correct Answer: D
, Explanation: Inability to move the digits distal to a cast is a warning sign of compartment
syndrome or nerve impairment. This requires immediate notification of the provider to
prevent permanent tissue damage or loss of limb. The nurse should also assess for the ‘5
Ps’: pain, pallor, pulselessness, paresthesia, and paralysis.
6. A nurse is providing discharge teaching for a child with a ventriculoperitoneal (VP) shunt.
Which symptom should the parents report immediately?
A. Mild headache relieved by acetaminophen
B. Increased appetite and weight gain
C. Sleeping for 8 hours at night
D. Vomiting and irritability
Correct Answer: D
Explanation: Vomiting, irritability, and a bulging fontanel (in infants) are classic signs of
VP shunt malfunction or infection leading to increased ICP. Parents must be educated to
recognize these signs as they indicate the shunt is not properly draining cerebrospinal
fluid. Early intervention is necessary to prevent neurological damage or brain herniation.
7. A child is diagnosed with Duchenne Muscular Dystrophy (DMD). Which of the following is a
characteristic early sign of this condition?
A. Hyperreflexia of the lower extremities
B. Gowers sign when rising from the floor
C. Early achievement of motor milestones
with Rationale | Chamberlain University
1. A nurse is assessing a child with a suspected head injury. Which of the following is the
earliest sign of increased intracranial pressure (ICP)?
A. Level of consciousness changes
B. Fixed and dilated pupils
C. Bradycardia
D. Cheyne-Stokes respirations
Correct Answer: A
Explanation: A change in the level of consciousness (LOC) is the most sensitive and
earliest indicator of neurological deterioration and increased ICP. In children, this may
manifest as irritability, restlessness, or decreased responsiveness to parents. Late signs of
increased ICP include Cushing’s triad (bradycardia, hypertension, and irregular
respirations) and pupillary changes.
2. A child is admitted with a diagnosis of bacterial meningitis. Which of the following results
would the nurse expect to find in the cerebrospinal fluid (CSF) analysis?
A. Increased glucose and decreased protein
B. Decreased glucose and increased protein
C. Clear appearance with normal pressure
,D. Absence of white blood cells
Correct Answer: B
Explanation: In bacterial meningitis, the CSF typically shows a decrease in glucose because
the bacteria consume it as a nutrient source. Protein levels are elevated due to the
inflammatory process and the presence of bacterial waste. The CSF will also appear cloudy
or turbid, and the opening pressure is usually elevated during the lumbar puncture.
3. The nurse is caring for a 10-year-old child with Type 1 Diabetes Mellitus who is planning to
play soccer. Which instruction should the nurse provide?
A. Decrease fluid intake before and during the game.
B. Eat a carbohydrate snack 30 minutes before exercise.
C. Administer an extra dose of insulin before the match.
D. Skip the soccer game if blood glucose is 150 mg/dL.
Correct Answer: B
Explanation: Physical activity increases the uptake of glucose by the muscles, which can
lead to hypoglycemia in children with Type 1 Diabetes. To prevent this, the child should
consume a carbohydrate snack before participating in vigorous exercise. The child should
also monitor blood glucose levels more frequently and carry a fast-acting glucose source
during the activity.
,4. A toddler is brought to the emergency department with a 25% total body surface area
(TBSA) burn. What is the priority nursing intervention during the first 24 hours?
A. Applying topical antibiotic ointment
B. Planning for skin grafting
C. Debriding the burn wounds
D. Initiating fluid resuscitation
Correct Answer: D
Explanation: Fluid resuscitation is the critical priority during the emergent phase of burn
care to prevent hypovolemic shock. Large amounts of fluid shift from the intravascular
space to the interstitial space following major burns. The nurse must monitor urine output
and vital signs closely to ensure adequate tissue perfusion and organ function.
5. Which assessment finding should the nurse prioritize in a child who has a new fiberglass
cast on the right lower leg?
A. The child reports the cast feels heavy.
B. Capillary refill of 2 seconds in the right toes.
C. Presence of a ‘hot spot’ on the surface of the cast.
D. The child is unable to wiggle the toes on the right foot.
Correct Answer: D
, Explanation: Inability to move the digits distal to a cast is a warning sign of compartment
syndrome or nerve impairment. This requires immediate notification of the provider to
prevent permanent tissue damage or loss of limb. The nurse should also assess for the ‘5
Ps’: pain, pallor, pulselessness, paresthesia, and paralysis.
6. A nurse is providing discharge teaching for a child with a ventriculoperitoneal (VP) shunt.
Which symptom should the parents report immediately?
A. Mild headache relieved by acetaminophen
B. Increased appetite and weight gain
C. Sleeping for 8 hours at night
D. Vomiting and irritability
Correct Answer: D
Explanation: Vomiting, irritability, and a bulging fontanel (in infants) are classic signs of
VP shunt malfunction or infection leading to increased ICP. Parents must be educated to
recognize these signs as they indicate the shunt is not properly draining cerebrospinal
fluid. Early intervention is necessary to prevent neurological damage or brain herniation.
7. A child is diagnosed with Duchenne Muscular Dystrophy (DMD). Which of the following is a
characteristic early sign of this condition?
A. Hyperreflexia of the lower extremities
B. Gowers sign when rising from the floor
C. Early achievement of motor milestones
