Pediatrics ATI Practice A QUESTIONS
AND ANSWERS
1. A charge nurse in an emergency department is preparing an in-service for a group of
newly licensed nurses about the manifestations of child maltreatment. Which of the
following manifestations should the charge nurse include as an indication of physical
maltreatment?
A. Recurrent urinary tract infections
B. Symmetric burns of the lower extremities
C. Failure to thrive
D. Lack of subcutaneous fat - ANS -B. Symmetric burns of the lower extremities
2. Rationale: The nurse should include that symmetric burns to the lower extremities can
indicate physical abuse. The patterns are usually characteristic of the method or object
used, such as cigar or cigarette burns, or burns in the shape of an iron.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the
preschooler's parents tells the nurse that they cannot cope anymore and are thinking
about moving out of the house. Which of the following statements should the nurse
make?
A. "It is important that you provide emotional support for your family at this time."
B. "You have to do what you feel is best. Everything will turn out fine."
C. "I know how you feel. This is an extremely stressful time for your family."
D. "Let's talk about some of the ways you have handled previous stressors in your life." -
ANS -D. "Let's talk about some of the ways you have handled previous stressors in your
life."
Rationale: This statement offers a general lead to allow the parent to express their
feelings and previous actions when faced with stressful situations. It also helps the
parent to focus on ways that they can cope with the current situation.
3. A nurse in an ED is caring for an adolescent experiencing an anaphylaxis reaction.
Which of the following is the priority action of the nurse?
A. Elevate the head of the child's bed.
B. Insert a large bore IV catheter for the child.
C. Determine the allergen that caused the child's reaction.
D. Administer epinephrine IM to the child. - ANS -D. Administer epinephrine IM to the
child.
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority action is administering epinephrine IM to the child.
During an anaphylactic reaction, histamine release causes bronchoconstriction and
, vasodilation. This is an emergency because ultimately this causes decreased blood
return to the heart.
4. A nurse in an emergency department is caring for an adolescent who has severe
abdominal pain due to appendicitis. Which of the following locations should the nurse
identify as McBurneys Point? - ANS -A - The nurse should identify this area of the
client's abdomen as McBurney's point. This area of the right lower quadrant located
about two-thirds of the way between the umbilicus and the client's anterosuperior iliac
spine is the area where a client who has appendicitis is most likely to report pain and
tenderness.
5. A nurse in an emergency department is performing a physical assessment on a
2-week-old male newborn. Which of the following findings is the priority for the nurse to
report to the provider?
A.Excoriated scrotal area
B. Multiple capillary hemangiomas
C. Depressed posterior fontanel
D. Substernal retractions - ANS -D. Substernal retractions
Rationale: When using the airway, breathing, and circulation approach to client care, the
nurse should determine that the priority finding to report to the provider is substernal
retractions. This finding indicates the newborn is experiencing increased respiratory
effort, which could quickly progress to respiratory failure.
6. A nurse in the ED is caring for a school-aged child who has appendicitis and rates their
pain as 7 on a scale of 1-10. which of the following actions should the nurse take?
A. Instill a 500 mL tap water enema.
B. Give morphine 0.05 mg/kg IV.
C. Administer polyethylene glycol 1g/kg PO
D. Apply a heating pad to the child's abdomen. - ANS -B. Give morphine 0.05 mg/kg IV.
7. Rationale: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should
administer an analgesic medication for pain relief.
A nurse in the emergency department is caring for a toddler who has partial-thickness
burns on their right arm. Which of the following actions should the nurse take?
A. Insert a nasogastric tube.
B. Initiate prophylactic antibiotic therapy.
C. Cleanse the affected area with mild soap and water.
D. Apply a topical corticosteroid to the affected area. - ANS -C. Cleanse the affected
area with mild soap and water.
Rationale: The nurse should wash the affected area with mild soap and water to remove
any loose tissue that could cause infection.
8. A nurse is a providers office is preparing to administer vaccinations to a toddler during a
well-child visit. Which of the actions should the nurse plan to take? (kid has increased
RR & HR; allergy to Neomycin)
A. Withhold the measles, mumps, and rubella (MMR) vaccine.
B. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine.
C. Withhold the influenza vaccine.
AND ANSWERS
1. A charge nurse in an emergency department is preparing an in-service for a group of
newly licensed nurses about the manifestations of child maltreatment. Which of the
following manifestations should the charge nurse include as an indication of physical
maltreatment?
A. Recurrent urinary tract infections
B. Symmetric burns of the lower extremities
C. Failure to thrive
D. Lack of subcutaneous fat - ANS -B. Symmetric burns of the lower extremities
2. Rationale: The nurse should include that symmetric burns to the lower extremities can
indicate physical abuse. The patterns are usually characteristic of the method or object
used, such as cigar or cigarette burns, or burns in the shape of an iron.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the
preschooler's parents tells the nurse that they cannot cope anymore and are thinking
about moving out of the house. Which of the following statements should the nurse
make?
A. "It is important that you provide emotional support for your family at this time."
B. "You have to do what you feel is best. Everything will turn out fine."
C. "I know how you feel. This is an extremely stressful time for your family."
D. "Let's talk about some of the ways you have handled previous stressors in your life." -
ANS -D. "Let's talk about some of the ways you have handled previous stressors in your
life."
Rationale: This statement offers a general lead to allow the parent to express their
feelings and previous actions when faced with stressful situations. It also helps the
parent to focus on ways that they can cope with the current situation.
3. A nurse in an ED is caring for an adolescent experiencing an anaphylaxis reaction.
Which of the following is the priority action of the nurse?
A. Elevate the head of the child's bed.
B. Insert a large bore IV catheter for the child.
C. Determine the allergen that caused the child's reaction.
D. Administer epinephrine IM to the child. - ANS -D. Administer epinephrine IM to the
child.
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority action is administering epinephrine IM to the child.
During an anaphylactic reaction, histamine release causes bronchoconstriction and
, vasodilation. This is an emergency because ultimately this causes decreased blood
return to the heart.
4. A nurse in an emergency department is caring for an adolescent who has severe
abdominal pain due to appendicitis. Which of the following locations should the nurse
identify as McBurneys Point? - ANS -A - The nurse should identify this area of the
client's abdomen as McBurney's point. This area of the right lower quadrant located
about two-thirds of the way between the umbilicus and the client's anterosuperior iliac
spine is the area where a client who has appendicitis is most likely to report pain and
tenderness.
5. A nurse in an emergency department is performing a physical assessment on a
2-week-old male newborn. Which of the following findings is the priority for the nurse to
report to the provider?
A.Excoriated scrotal area
B. Multiple capillary hemangiomas
C. Depressed posterior fontanel
D. Substernal retractions - ANS -D. Substernal retractions
Rationale: When using the airway, breathing, and circulation approach to client care, the
nurse should determine that the priority finding to report to the provider is substernal
retractions. This finding indicates the newborn is experiencing increased respiratory
effort, which could quickly progress to respiratory failure.
6. A nurse in the ED is caring for a school-aged child who has appendicitis and rates their
pain as 7 on a scale of 1-10. which of the following actions should the nurse take?
A. Instill a 500 mL tap water enema.
B. Give morphine 0.05 mg/kg IV.
C. Administer polyethylene glycol 1g/kg PO
D. Apply a heating pad to the child's abdomen. - ANS -B. Give morphine 0.05 mg/kg IV.
7. Rationale: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should
administer an analgesic medication for pain relief.
A nurse in the emergency department is caring for a toddler who has partial-thickness
burns on their right arm. Which of the following actions should the nurse take?
A. Insert a nasogastric tube.
B. Initiate prophylactic antibiotic therapy.
C. Cleanse the affected area with mild soap and water.
D. Apply a topical corticosteroid to the affected area. - ANS -C. Cleanse the affected
area with mild soap and water.
Rationale: The nurse should wash the affected area with mild soap and water to remove
any loose tissue that could cause infection.
8. A nurse is a providers office is preparing to administer vaccinations to a toddler during a
well-child visit. Which of the actions should the nurse plan to take? (kid has increased
RR & HR; allergy to Neomycin)
A. Withhold the measles, mumps, and rubella (MMR) vaccine.
B. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine.
C. Withhold the influenza vaccine.
