NUR 203 Peds Exam 1 Actual Questions with 100%
Correct Answers | Verified | Latest Update- Fortis
College
1) A nurse is conducting an admission interview with the mother of a 2 year old child. What
history question is most important at this time?
a. How many children are in the family?
b. What is your child's normal routine?
c. Does your child attend daycare?
d. What toys are most important to your child?
Answer: B. What is your child's normal routine?
Expert Rationale:
A 2-year-old is strongly affected by changes in routine and environment. Obtaining information
about the child's normal eating, sleeping, toileting, comfort, and daily routines helps the nurse
establish developmentally appropriate care and identify behaviors that may indicate distress.
Maintaining familiar routines can reduce anxiety and promote a sense of security during
hospitalization. Questions about daycare, siblings, and favorite toys may also be useful, but the
child's normal routine provides broader information for individualized nursing care.
2) A 9 month old is sitting on his father's lap at the bedside. The nurse needs to do a shift
assessment. How should the nurse proceed?
a. Ask the father to put the child in bed, and proceed with the exam.
b. Talk with the father for a few minutes, before examining child.
c. Listen to the heart and lungs of the child.
d. Take the child from the father, and proceed with the exam.
Answer: C. Listen to the heart and lungs of the child.
Expert Rationale:
For an infant, the nurse should take advantage of the child's quiet and secure state while being
held by a parent. Auscultating the heart and lungs can often be performed without significantly
disturbing the infant. A full assessment should proceed from the least distressing interventions
,to more invasive or upsetting procedures. Removing the infant from the parent's lap may
increase anxiety and crying, which can interfere with assessment findings.
3) Which nursing intervention best supports the concept of atraumatic care for a hospitalized
child?
a. Allowing parents to visit once every shift.
b. Encouraging six year old to be brave during an IV start.
c. Allowing adolescent to keep the hospital door shut.
d. Asking parents of baby to wait outside treatment room door during spinal tap.
Answer: C. Allowing adolescent to keep the hospital door shut.
Expert Rationale:
Atraumatic care focuses on minimizing physical and psychological distress for children and
families. Respecting an adolescent's privacy by allowing the hospital door to remain closed
when appropriate supports dignity, control, and emotional well-being. Encouraging a child to
"be brave" does not eliminate distress, and separating parents from children during procedures
generally increases anxiety rather than reducing it. Restricting parental visitation also conflicts
with family-centered care.
4) A six year old is in the recovery room following an appendectomy. He is not yet fully awake,
though he opens his eyes when his name is called. Which pain assessment tool would be most
effective for the nurse to use at this time?
a. OUCHER assessment tool.
b. Wong's FACES assessment tool.
c. FLAACC pain assessment tool.
d. 1-10 verbal assessment scale.
Answer: C. FLAACC pain assessment tool.
Expert Rationale:
The FLACC scale evaluates pain using observable behaviors: Face, Legs, Activity, Cry, and
Consolability. It is particularly useful for children who are unable to reliably self-report pain,
including a child who is not fully awake after surgery. Wong's FACES and numeric/verbal scales
, require sufficient cognitive ability and communication to provide a reliable self-report. Because
this child is only minimally responsive, behavioral assessment is most appropriate.
5) A nurse enters the room of an 8-year-old child newly admitted and diagnosed with type I
diabetes. His mother is sitting in a chair at his bedside. What should the nurse do first?
a. Go the bedside and meet the child.
b. Stand by the door, and say "I am the assigned nurse today."
c. Go over to the mother and ask what brought the child into the hospital today.
d. Explain the use of the call light to child.
Answer: A. Go the bedside and meet the child.
Expert Rationale:
The nurse should first establish a therapeutic relationship with the child, while also recognizing
the parent's role in family-centered care. An 8-year-old is school-age and should be directly
involved in communication about their care. Approaching the child at the bedside demonstrates
respect and helps establish trust. Assessment and teaching should then proceed according to
the child's condition and immediate needs.
6) Which hospitalized child would the nurse be most worried about as needing support or
follow-up?
a. The 9-month-old that cries when the nurse walks in the room.
b. The 2-year-old that holds still during an IV start.
c. An adolescent that asks her father to leave the room during an assessment.
d. A school-age child that angrily throws his food tray on the floor.
Answer: B. The 2-year-old that holds still during an IV start.
Expert Rationale:
A 2-year-old commonly responds to painful procedures with crying, resistance, and attempts to
escape. An unusually quiet or motionless response during a painful procedure can indicate
withdrawal, fear, or a high level of distress. The nurse should assess the child's emotional
response and provide appropriate support. Crying in an infant when an unfamiliar nurse enters
Correct Answers | Verified | Latest Update- Fortis
College
1) A nurse is conducting an admission interview with the mother of a 2 year old child. What
history question is most important at this time?
a. How many children are in the family?
b. What is your child's normal routine?
c. Does your child attend daycare?
d. What toys are most important to your child?
Answer: B. What is your child's normal routine?
Expert Rationale:
A 2-year-old is strongly affected by changes in routine and environment. Obtaining information
about the child's normal eating, sleeping, toileting, comfort, and daily routines helps the nurse
establish developmentally appropriate care and identify behaviors that may indicate distress.
Maintaining familiar routines can reduce anxiety and promote a sense of security during
hospitalization. Questions about daycare, siblings, and favorite toys may also be useful, but the
child's normal routine provides broader information for individualized nursing care.
2) A 9 month old is sitting on his father's lap at the bedside. The nurse needs to do a shift
assessment. How should the nurse proceed?
a. Ask the father to put the child in bed, and proceed with the exam.
b. Talk with the father for a few minutes, before examining child.
c. Listen to the heart and lungs of the child.
d. Take the child from the father, and proceed with the exam.
Answer: C. Listen to the heart and lungs of the child.
Expert Rationale:
For an infant, the nurse should take advantage of the child's quiet and secure state while being
held by a parent. Auscultating the heart and lungs can often be performed without significantly
disturbing the infant. A full assessment should proceed from the least distressing interventions
,to more invasive or upsetting procedures. Removing the infant from the parent's lap may
increase anxiety and crying, which can interfere with assessment findings.
3) Which nursing intervention best supports the concept of atraumatic care for a hospitalized
child?
a. Allowing parents to visit once every shift.
b. Encouraging six year old to be brave during an IV start.
c. Allowing adolescent to keep the hospital door shut.
d. Asking parents of baby to wait outside treatment room door during spinal tap.
Answer: C. Allowing adolescent to keep the hospital door shut.
Expert Rationale:
Atraumatic care focuses on minimizing physical and psychological distress for children and
families. Respecting an adolescent's privacy by allowing the hospital door to remain closed
when appropriate supports dignity, control, and emotional well-being. Encouraging a child to
"be brave" does not eliminate distress, and separating parents from children during procedures
generally increases anxiety rather than reducing it. Restricting parental visitation also conflicts
with family-centered care.
4) A six year old is in the recovery room following an appendectomy. He is not yet fully awake,
though he opens his eyes when his name is called. Which pain assessment tool would be most
effective for the nurse to use at this time?
a. OUCHER assessment tool.
b. Wong's FACES assessment tool.
c. FLAACC pain assessment tool.
d. 1-10 verbal assessment scale.
Answer: C. FLAACC pain assessment tool.
Expert Rationale:
The FLACC scale evaluates pain using observable behaviors: Face, Legs, Activity, Cry, and
Consolability. It is particularly useful for children who are unable to reliably self-report pain,
including a child who is not fully awake after surgery. Wong's FACES and numeric/verbal scales
, require sufficient cognitive ability and communication to provide a reliable self-report. Because
this child is only minimally responsive, behavioral assessment is most appropriate.
5) A nurse enters the room of an 8-year-old child newly admitted and diagnosed with type I
diabetes. His mother is sitting in a chair at his bedside. What should the nurse do first?
a. Go the bedside and meet the child.
b. Stand by the door, and say "I am the assigned nurse today."
c. Go over to the mother and ask what brought the child into the hospital today.
d. Explain the use of the call light to child.
Answer: A. Go the bedside and meet the child.
Expert Rationale:
The nurse should first establish a therapeutic relationship with the child, while also recognizing
the parent's role in family-centered care. An 8-year-old is school-age and should be directly
involved in communication about their care. Approaching the child at the bedside demonstrates
respect and helps establish trust. Assessment and teaching should then proceed according to
the child's condition and immediate needs.
6) Which hospitalized child would the nurse be most worried about as needing support or
follow-up?
a. The 9-month-old that cries when the nurse walks in the room.
b. The 2-year-old that holds still during an IV start.
c. An adolescent that asks her father to leave the room during an assessment.
d. A school-age child that angrily throws his food tray on the floor.
Answer: B. The 2-year-old that holds still during an IV start.
Expert Rationale:
A 2-year-old commonly responds to painful procedures with crying, resistance, and attempts to
escape. An unusually quiet or motionless response during a painful procedure can indicate
withdrawal, fear, or a high level of distress. The nurse should assess the child's emotional
response and provide appropriate support. Crying in an infant when an unfamiliar nurse enters
