,ASU NUR 425 Exam 3 | Health and Illness Concepts: Adults and
Pediatrics (2026) Q&A
1. A nurse is assessing a 3-year-old child who presents with a fever of 39.5°C
(103.1°F) and a generalized tonic-clonic seizure that lasted 4 minutes. The child has
no history of seizures. What is the nurse's priority action?
A) Administer rectal diazepam immediately
B) Prepare for a lumbar puncture
C) Position the child on the side and maintain a patent airway
D) Initiate a peripheral IV for anticonvulsant administration
Correct Answer: Position the child on the side and maintain a patent airway
Rationale: During a seizure, the priority is to protect the airway and prevent
aspiration. Positioning the child on the side helps maintain a patent airway. This is a
febrile seizure, and the seizure has already stopped; the priority is postictal
management and airway protection.
2. Which vaccination is most important for preventing bacterial meningitis and acute
epiglottitis in infants?
A) DTap vaccine
B) Meningococcal polysaccharide vaccine (Menactra)
C) Hib vaccine
D) Pneumococcal conjugate vaccine (PCV13)
Correct Answer: Hib vaccine
,Rationale: The Haemophilus influenzae type b (Hib) vaccine protects children
against acute epiglottitis and bacterial meningitis, two serious and potentially life-
threatening infections in infants.
3. A nurse is caring for a child with suspected bacterial meningitis. Which assessment
finding would be most concerning?
A) Positive Kernig's sign
B) Nuchal rigidity
C) Bulging fontanel in an infant
D) Fever and irritability
Correct Answer: Bulging fontanel in an infant
Rationale: A bulging fontanel in an infant is a sign of increased intracranial pressure
(ICP) and requires immediate intervention. Kernig's sign, nuchal rigidity, fever, and
irritability are also signs of meningitis, but a bulging fontanel indicates a more urgent
neurological compromise.
4. A nurse is teaching the parents of a child with a new diagnosis of epilepsy about
seizure precautions. Which statement by the parent indicates a need for further
teaching?
A) "I will keep the child's head turned to the side during a seizure."
B) "I will place a padded tongue blade in the child's mouth to prevent injury."
C) "I will time the seizure and note the child's behavior."
D) "I will remove any nearby objects that could cause injury."
Correct Answer: "I will place a padded tongue blade in the child's mouth to prevent
injury."
, Rationale: Placing anything in the mouth during a seizure is contraindicated because
it can cause airway obstruction, dental injury, or aspiration. The priority is to maintain
a patent airway and protect the child from injury.
5. A child is diagnosed with hydrocephalus and a ventriculoperitoneal (VP) shunt is
placed. Which postoperative finding requires immediate notification of the
healthcare provider?
A) Irritability and vomiting
B) Sunken fontanel
C) Decreased head circumference
D) Improvement in feeding
Correct Answer: Irritability and vomiting
Rationale: Irritability and vomiting are signs of increased intracranial pressure and
possible shunt malfunction or infection. These findings require immediate
assessment. Sunken fontanel and decreased head circumference are not typical
concerns for hydrocephalus.
6. A nurse is assessing a newborn with spina bifida. Which finding is most important
to report?
A) A sac containing cerebrospinal fluid on the lower spine
B) Diminished reflexes in the lower extremities
C) A red, moist, and intact sac over the spinal defect
D) Flaccid paralysis of the lower extremities
Correct Answer: A red, moist, and intact sac over the spinal defect
Pediatrics (2026) Q&A
1. A nurse is assessing a 3-year-old child who presents with a fever of 39.5°C
(103.1°F) and a generalized tonic-clonic seizure that lasted 4 minutes. The child has
no history of seizures. What is the nurse's priority action?
A) Administer rectal diazepam immediately
B) Prepare for a lumbar puncture
C) Position the child on the side and maintain a patent airway
D) Initiate a peripheral IV for anticonvulsant administration
Correct Answer: Position the child on the side and maintain a patent airway
Rationale: During a seizure, the priority is to protect the airway and prevent
aspiration. Positioning the child on the side helps maintain a patent airway. This is a
febrile seizure, and the seizure has already stopped; the priority is postictal
management and airway protection.
2. Which vaccination is most important for preventing bacterial meningitis and acute
epiglottitis in infants?
A) DTap vaccine
B) Meningococcal polysaccharide vaccine (Menactra)
C) Hib vaccine
D) Pneumococcal conjugate vaccine (PCV13)
Correct Answer: Hib vaccine
,Rationale: The Haemophilus influenzae type b (Hib) vaccine protects children
against acute epiglottitis and bacterial meningitis, two serious and potentially life-
threatening infections in infants.
3. A nurse is caring for a child with suspected bacterial meningitis. Which assessment
finding would be most concerning?
A) Positive Kernig's sign
B) Nuchal rigidity
C) Bulging fontanel in an infant
D) Fever and irritability
Correct Answer: Bulging fontanel in an infant
Rationale: A bulging fontanel in an infant is a sign of increased intracranial pressure
(ICP) and requires immediate intervention. Kernig's sign, nuchal rigidity, fever, and
irritability are also signs of meningitis, but a bulging fontanel indicates a more urgent
neurological compromise.
4. A nurse is teaching the parents of a child with a new diagnosis of epilepsy about
seizure precautions. Which statement by the parent indicates a need for further
teaching?
A) "I will keep the child's head turned to the side during a seizure."
B) "I will place a padded tongue blade in the child's mouth to prevent injury."
C) "I will time the seizure and note the child's behavior."
D) "I will remove any nearby objects that could cause injury."
Correct Answer: "I will place a padded tongue blade in the child's mouth to prevent
injury."
, Rationale: Placing anything in the mouth during a seizure is contraindicated because
it can cause airway obstruction, dental injury, or aspiration. The priority is to maintain
a patent airway and protect the child from injury.
5. A child is diagnosed with hydrocephalus and a ventriculoperitoneal (VP) shunt is
placed. Which postoperative finding requires immediate notification of the
healthcare provider?
A) Irritability and vomiting
B) Sunken fontanel
C) Decreased head circumference
D) Improvement in feeding
Correct Answer: Irritability and vomiting
Rationale: Irritability and vomiting are signs of increased intracranial pressure and
possible shunt malfunction or infection. These findings require immediate
assessment. Sunken fontanel and decreased head circumference are not typical
concerns for hydrocephalus.
6. A nurse is assessing a newborn with spina bifida. Which finding is most important
to report?
A) A sac containing cerebrospinal fluid on the lower spine
B) Diminished reflexes in the lower extremities
C) A red, moist, and intact sac over the spinal defect
D) Flaccid paralysis of the lower extremities
Correct Answer: A red, moist, and intact sac over the spinal defect
