WONG’S NURSING CARE OF INFANTS
AND CHILDREN, 12TH EDITION
TEST BANK
1
Reference
Ch. 1 — Perspectives of Pediatric Nursing — “Providing Nursing
Care to Children and Families” / Clinical Judgment
Stem
A 4-year-old preschooler is admitted with a 24-hour history of
fever and new onset lethargy. The child is listless, has poor eye
contact, and a caregiver reports decreased oral intake. Using
the six essential cognitive skills of clinical judgment, which
nurse action should occur first?
A. Generate possible nursing diagnoses.
B. Recognize and document the abnormal cues (lethargy, poor
intake, decreased responsiveness).
C. Immediately implement oral rehydration therapy.
D. Prioritize interventions and call the provider for orders.
,Correct answer
B
Rationale — Correct (B)
Recognition of cues is the initial cognitive skill in clinical
judgment; the nurse must first notice and document abnormal
findings (lethargy, poor intake, altered interaction) to guide
analysis. Accurate cue recognition frames subsequent analysis,
hypothesis formulation, and safe prioritization. This step aligns
with Wong’s sequence for clinical reasoning and supports
family-centered communication by clearly reporting observable
concerns.
Rationale — Incorrect
A. Generating diagnoses before recognizing/collecting cues risks
error because diagnoses require validated data.
C. Implementing oral rehydration without assessing airway,
breathing, circulation, or determining ability to tolerate PO is
premature and possibly unsafe.
D. Prioritization requires analyzed cues and hypotheses; calling
the provider without these may produce unfocused orders.
Teaching point
First recognize and document abnormal cues; this guides safe
analysis and priorities.
Citation
Hockenberry, M. J., & Rodgers, C. C. (2024). Wong’s Nursing
Care of Infants and Children (12th ed.). Chapter 1.
,2
Reference
Ch. 1 — Six Essential Cognitive Skills of Clinical Judgment —
“Recognize Cues vs. Analyze Cues”
Stem
A 2-month-old infant presents to triage with a history of
decreased feeding, fewer wet diapers, and a respiratory rate of
70/min. The infant’s color is pale and capillary refill is 4 seconds.
After recognizing these cues, which analytic statement should
the nurse make first?
A. “This infant likely has an upper respiratory infection only.”
B. “The tachypnea and poor perfusion suggest possible
respiratory distress with early circulatory compromise.”
C. “No immediate action; advise follow-up with primary care in
48 hours.”
D. “Begin anticipatory guidance about routine immunizations.”
Correct answer
B
Rationale — Correct (B)
After recognition, analyze cues for significance: tachypnea,
decreased perfusion (prolonged capillary refill), poor feeding
indicate potential respiratory compromise and dehydration or
shock. This analytic synthesis justifies urgent assessment and
, intervention. Wong emphasizes moving from cue recognition to
analysis before generating solutions.
Rationale — Incorrect
A. Narrowly labeling as URI ignores signs of poor perfusion and
feeding—dangerous underestimation.
C. Delaying care risks deterioration; clinical cues signal need for
immediate evaluation.
D. Immunization counseling is unrelated to acute risk and
inappropriate priority.
Teaching point
Analyze combined cues (respiratory rate + perfusion + intake) to
detect early deterioration.
Citation
Hockenberry, M. J., & Rodgers, C. C. (2024). Wong’s Nursing
Care of Infants and Children (12th ed.). Chapter 1.
3
Reference
Ch. 1 — Six Essential Cognitive Skills — “Prioritizing Hypotheses
and Generating Solutions”
Stem
A 5-year-old with asthma presents at night with increased work
of breathing, audible wheeze, and oxygen saturation 90% on
room air. After recognizing and analyzing cues, which
AND CHILDREN, 12TH EDITION
TEST BANK
1
Reference
Ch. 1 — Perspectives of Pediatric Nursing — “Providing Nursing
Care to Children and Families” / Clinical Judgment
Stem
A 4-year-old preschooler is admitted with a 24-hour history of
fever and new onset lethargy. The child is listless, has poor eye
contact, and a caregiver reports decreased oral intake. Using
the six essential cognitive skills of clinical judgment, which
nurse action should occur first?
A. Generate possible nursing diagnoses.
B. Recognize and document the abnormal cues (lethargy, poor
intake, decreased responsiveness).
C. Immediately implement oral rehydration therapy.
D. Prioritize interventions and call the provider for orders.
,Correct answer
B
Rationale — Correct (B)
Recognition of cues is the initial cognitive skill in clinical
judgment; the nurse must first notice and document abnormal
findings (lethargy, poor intake, altered interaction) to guide
analysis. Accurate cue recognition frames subsequent analysis,
hypothesis formulation, and safe prioritization. This step aligns
with Wong’s sequence for clinical reasoning and supports
family-centered communication by clearly reporting observable
concerns.
Rationale — Incorrect
A. Generating diagnoses before recognizing/collecting cues risks
error because diagnoses require validated data.
C. Implementing oral rehydration without assessing airway,
breathing, circulation, or determining ability to tolerate PO is
premature and possibly unsafe.
D. Prioritization requires analyzed cues and hypotheses; calling
the provider without these may produce unfocused orders.
Teaching point
First recognize and document abnormal cues; this guides safe
analysis and priorities.
Citation
Hockenberry, M. J., & Rodgers, C. C. (2024). Wong’s Nursing
Care of Infants and Children (12th ed.). Chapter 1.
,2
Reference
Ch. 1 — Six Essential Cognitive Skills of Clinical Judgment —
“Recognize Cues vs. Analyze Cues”
Stem
A 2-month-old infant presents to triage with a history of
decreased feeding, fewer wet diapers, and a respiratory rate of
70/min. The infant’s color is pale and capillary refill is 4 seconds.
After recognizing these cues, which analytic statement should
the nurse make first?
A. “This infant likely has an upper respiratory infection only.”
B. “The tachypnea and poor perfusion suggest possible
respiratory distress with early circulatory compromise.”
C. “No immediate action; advise follow-up with primary care in
48 hours.”
D. “Begin anticipatory guidance about routine immunizations.”
Correct answer
B
Rationale — Correct (B)
After recognition, analyze cues for significance: tachypnea,
decreased perfusion (prolonged capillary refill), poor feeding
indicate potential respiratory compromise and dehydration or
shock. This analytic synthesis justifies urgent assessment and
, intervention. Wong emphasizes moving from cue recognition to
analysis before generating solutions.
Rationale — Incorrect
A. Narrowly labeling as URI ignores signs of poor perfusion and
feeding—dangerous underestimation.
C. Delaying care risks deterioration; clinical cues signal need for
immediate evaluation.
D. Immunization counseling is unrelated to acute risk and
inappropriate priority.
Teaching point
Analyze combined cues (respiratory rate + perfusion + intake) to
detect early deterioration.
Citation
Hockenberry, M. J., & Rodgers, C. C. (2024). Wong’s Nursing
Care of Infants and Children (12th ed.). Chapter 1.
3
Reference
Ch. 1 — Six Essential Cognitive Skills — “Prioritizing Hypotheses
and Generating Solutions”
Stem
A 5-year-old with asthma presents at night with increased work
of breathing, audible wheeze, and oxygen saturation 90% on
room air. After recognizing and analyzing cues, which
