1. Priority Question
The pediatric nurse receives four telephone calls. Which parent should the
nurse instruct to call emergency medical services?
A. The parent of a 3-year-old with a temperature of 100.8°F who is drinking
fluids
B. The parent of a 6-month-old who is difficult to awaken and has irregular
breathing
C. The parent of a 7-year-old with nasal congestion for 2 days
D. The parent of a 10-year-old with a mild headache after school
Correct answer: B
Rationale: Altered responsiveness and irregular breathing suggest possible
respiratory or neurologic compromise. Airway and breathing concerns
require emergency evaluation. The other findings may require monitoring
or nonemergency care.
2. Correct Understanding
A nursing student explains the purpose of a pediatric interview. Which
statement demonstrates correct understanding?
A. “The interview is primarily a social conversation used to establish
rapport.”
B. “The interview is goal-directed communication used to collect relevant
information.”
C. “Most questions should be directed to the parent rather than the child.”
D. “The nurse should use closed-ended questions throughout the interview.”
Correct answer: B
Rationale: A professional interview is goal-directed and organized to
collect health, developmental, psychosocial, and family information.
Children should be included according to their developmental ability, and
open-ended questions are useful for encouraging detailed responses.
3. Select All That Apply
Which actions help establish an appropriate setting for a pediatric
interview? Select all that apply.
,A. Reduce environmental distractions.
B. Ask family members how they prefer to be addressed.
C. Provide play materials for young children.
D. Conduct sensitive discussions in a public hallway.
E. Include the child in the introduction.
F. Keep the television playing to prevent silence.
Correct answers: A, B, C, E
Rationale: Privacy, limited distractions, respectful introductions, and age-
appropriate play help families participate in the interview. Sensitive
conversations should occur privately, and unnecessary noise should be
reduced.
4. Need for Further Teaching
The nurse is orienting a new employee to electronic health records. Which
statement indicates a need for further teaching?
A. “I will secure my password and avoid sharing it.”
B. “I may review a child’s record when I am assigned to the child’s care.”
C. “I can leave the record open when I step away briefly from the
computer.”
D. “I will protect confidential information from unauthorized disclosure.”
Correct answer: C
Rationale: The nurse should log out or secure the computer whenever
leaving it unattended. An open electronic record may expose confidential
information to unauthorized individuals.
5. Priority Question
During an adolescent interview, the patient states, “I have been thinking
about taking my father’s pills tonight.” What is the nurse’s priority
response?
A. “You should discuss these feelings with your parents.”
B. “Tell me what pills are available and whether you have a specific plan.”
C. “Many teenagers feel overwhelmed at times.”
D. “I will keep this information between us.”
, Correct answer: B
Rationale: The nurse must immediately assess suicidal intent, plan, timing,
and access to means. Confidentiality cannot be guaranteed when a patient
is at risk of harming self or others.
6. Correct Understanding
Which statement by the nurse best explains confidentiality to an
adolescent?
A. “Everything you tell me will remain confidential.”
B. “I will share everything with your parents after the interview.”
C. “Most information is private, but I must act if you are in danger.”
D. “Confidentiality applies after you turn 18.”
Correct answer: C
Rationale: Adolescents should understand both the protection and limits of
confidentiality. Information suggesting abuse, suicidal intent, or danger to
others requires appropriate disclosure to protect safety.
7. Select All That Apply
Which information should the nurse document during pediatric telephone
triage? Select all that apply.
A. Date and time of the call
B. Child’s age and contact information
C. Severity and duration of symptoms
D. Current medications and allergies
E. Advice provided to the caregiver
F. The nurse’s personal opinion of the caregiver
Correct answers: A, B, C, D, E
Rationale: Telephone triage documentation includes identifying
information, health background, symptoms, interventions already
attempted, disposition, advice, and follow-up instructions. Personal
judgments are not appropriate clinical documentation.
The pediatric nurse receives four telephone calls. Which parent should the
nurse instruct to call emergency medical services?
A. The parent of a 3-year-old with a temperature of 100.8°F who is drinking
fluids
B. The parent of a 6-month-old who is difficult to awaken and has irregular
breathing
C. The parent of a 7-year-old with nasal congestion for 2 days
D. The parent of a 10-year-old with a mild headache after school
Correct answer: B
Rationale: Altered responsiveness and irregular breathing suggest possible
respiratory or neurologic compromise. Airway and breathing concerns
require emergency evaluation. The other findings may require monitoring
or nonemergency care.
2. Correct Understanding
A nursing student explains the purpose of a pediatric interview. Which
statement demonstrates correct understanding?
A. “The interview is primarily a social conversation used to establish
rapport.”
B. “The interview is goal-directed communication used to collect relevant
information.”
C. “Most questions should be directed to the parent rather than the child.”
D. “The nurse should use closed-ended questions throughout the interview.”
Correct answer: B
Rationale: A professional interview is goal-directed and organized to
collect health, developmental, psychosocial, and family information.
Children should be included according to their developmental ability, and
open-ended questions are useful for encouraging detailed responses.
3. Select All That Apply
Which actions help establish an appropriate setting for a pediatric
interview? Select all that apply.
,A. Reduce environmental distractions.
B. Ask family members how they prefer to be addressed.
C. Provide play materials for young children.
D. Conduct sensitive discussions in a public hallway.
E. Include the child in the introduction.
F. Keep the television playing to prevent silence.
Correct answers: A, B, C, E
Rationale: Privacy, limited distractions, respectful introductions, and age-
appropriate play help families participate in the interview. Sensitive
conversations should occur privately, and unnecessary noise should be
reduced.
4. Need for Further Teaching
The nurse is orienting a new employee to electronic health records. Which
statement indicates a need for further teaching?
A. “I will secure my password and avoid sharing it.”
B. “I may review a child’s record when I am assigned to the child’s care.”
C. “I can leave the record open when I step away briefly from the
computer.”
D. “I will protect confidential information from unauthorized disclosure.”
Correct answer: C
Rationale: The nurse should log out or secure the computer whenever
leaving it unattended. An open electronic record may expose confidential
information to unauthorized individuals.
5. Priority Question
During an adolescent interview, the patient states, “I have been thinking
about taking my father’s pills tonight.” What is the nurse’s priority
response?
A. “You should discuss these feelings with your parents.”
B. “Tell me what pills are available and whether you have a specific plan.”
C. “Many teenagers feel overwhelmed at times.”
D. “I will keep this information between us.”
, Correct answer: B
Rationale: The nurse must immediately assess suicidal intent, plan, timing,
and access to means. Confidentiality cannot be guaranteed when a patient
is at risk of harming self or others.
6. Correct Understanding
Which statement by the nurse best explains confidentiality to an
adolescent?
A. “Everything you tell me will remain confidential.”
B. “I will share everything with your parents after the interview.”
C. “Most information is private, but I must act if you are in danger.”
D. “Confidentiality applies after you turn 18.”
Correct answer: C
Rationale: Adolescents should understand both the protection and limits of
confidentiality. Information suggesting abuse, suicidal intent, or danger to
others requires appropriate disclosure to protect safety.
7. Select All That Apply
Which information should the nurse document during pediatric telephone
triage? Select all that apply.
A. Date and time of the call
B. Child’s age and contact information
C. Severity and duration of symptoms
D. Current medications and allergies
E. Advice provided to the caregiver
F. The nurse’s personal opinion of the caregiver
Correct answers: A, B, C, D, E
Rationale: Telephone triage documentation includes identifying
information, health background, symptoms, interventions already
attempted, disposition, advice, and follow-up instructions. Personal
judgments are not appropriate clinical documentation.
