NSG434 Exam 4 Actual Exam Style V1 |
NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 6-year-old child is brought to the emergency department with a suspected diagnosis of
hypovolemic shock following severe diarrhea. What is the nurse’s priority action?
A. Administer an oral rehydration solution slowly.
B. Administer a dose of antidiarrheal medication.
C. Prepare the child for an immediate abdominal ultrasound.
D. Initiate an intravenous bolus of 20 mL/kg of normal saline.
Answer: D
Rationale: In pediatric patients, hypovolemic shock requires immediate fluid resuscitation
to restore circulating volume and maintain organ perfusion. The standard initial bolus is 20
mL/kg of an isotonic crystalloid such as normal saline or Lactated Ringer’s. This
intervention is prioritized over oral rehydration in the emergency setting when signs of
shock are present.
2. A nurse is assessing a 4-year-old child with multiple bruises in various stages of healing on
the back and buttocks. Which action is legally required of the nurse?
A. Report the suspected abuse to the local child protective services.
B. Document the findings and wait for the next visit to see if more appear.
,C. Confront the parents about the origin of the bruises.
D. Ask the child privately if their parents hit them.
Answer: A
Rationale: Nurses are mandated reporters and must report any suspicion of child abuse or
neglect to the appropriate authorities immediately. Bruises in different stages of healing on
non-bony prominences are a significant red flag for physical abuse. The nurse is not
required to prove abuse, only to report the suspicion to ensure the child’s safety.
3. A pediatric patient is exhibiting signs of septic shock, including tachycardia, bounding
pulses, and warm, flushed skin. Which stage of shock is the child likely experiencing?
A. Decompensated shock
B. Early (warm) septic shock
C. Hypovolemic shock
D. Late (cold) septic shock
Answer: B
Rationale: Early septic shock, also known as ‘warm shock,’ is characterized by peripheral
vasodilation which causes warm, flushed skin and bounding pulses. This occurs as the body
attempts to compensate for the infection by increasing cardiac output. As the condition
progresses, the child will enter the ‘cold’ stage with poor perfusion and hypotension.
,4. An adolescent is admitted to the psychiatric unit with a diagnosis of Major Depressive
Disorder and has started taking a Selective Serotonin Reuptake Inhibitor (SSRI). What is the
most important nursing intervention during the first two weeks of therapy?
A. Monitor for an immediate increase in appetite and weight gain.
B. Encourage the patient to avoid all social interactions.
C. Assess for increased energy levels and suicidal ideation.
D. Stop the medication if the patient feels slightly nauseated.
Answer: C
Rationale: When starting SSRIs, adolescents may experience a surge in energy before their
mood significantly improves, which can increase the risk of acting on suicidal thoughts. The
Black Box warning for SSRIs in this age group highlights the risk of increased suicidality
during the early phase of treatment. Close monitoring and safety planning are essential
nursing responsibilities during this time.
5. A 10-year-old child is brought to the ED after being hit by a car. The child is irritable and
complains of a headache. The nurse notes a widening pulse pressure and bradycardia. What
does this suggest?
A. Hypovolemic shock from internal bleeding
B. Normal physiological response to trauma
C. Increasing intracranial pressure (Cushing’s triad)
D. A localized infection from the injury site
, Answer: C
Rationale: Cushing’s triad consists of bradycardia, widening pulse pressure (increased
systolic BP), and irregular respirations. These signs indicate a significant increase in
intracranial pressure and are a late sign of brain herniation. Immediate intervention is
required to stabilize the child and prevent permanent neurological damage.
6. Which nursing intervention is most appropriate for a child diagnosed with Autism
Spectrum Disorder (ASD) who is hospitalized?
A. Provide a high-stimulation environment to encourage social interaction.
B. Maintain a consistent daily routine and use clear, simple communication.
C. Change the nurse assigned to the child every shift to prevent attachment.
D. Ensure the room is near the nurse’s station with the door open at all times.
Answer: B
Rationale: Children with ASD thrive on predictability and routine, which helps reduce
anxiety in the unfamiliar hospital environment. Clear and simple communication
accommodates their specific processing needs and social communication challenges.
Minimizing sensory triggers and maintaining a calm environment also supports better
coping for the child.
7. A child is admitted with a diagnosis of Munchausen Syndrome by Proxy (MSBP). What
should the nurse prioritize in the care plan?
A. Encouraging the parent to provide all the child’s bedside care.
NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 6-year-old child is brought to the emergency department with a suspected diagnosis of
hypovolemic shock following severe diarrhea. What is the nurse’s priority action?
A. Administer an oral rehydration solution slowly.
B. Administer a dose of antidiarrheal medication.
C. Prepare the child for an immediate abdominal ultrasound.
D. Initiate an intravenous bolus of 20 mL/kg of normal saline.
Answer: D
Rationale: In pediatric patients, hypovolemic shock requires immediate fluid resuscitation
to restore circulating volume and maintain organ perfusion. The standard initial bolus is 20
mL/kg of an isotonic crystalloid such as normal saline or Lactated Ringer’s. This
intervention is prioritized over oral rehydration in the emergency setting when signs of
shock are present.
2. A nurse is assessing a 4-year-old child with multiple bruises in various stages of healing on
the back and buttocks. Which action is legally required of the nurse?
A. Report the suspected abuse to the local child protective services.
B. Document the findings and wait for the next visit to see if more appear.
,C. Confront the parents about the origin of the bruises.
D. Ask the child privately if their parents hit them.
Answer: A
Rationale: Nurses are mandated reporters and must report any suspicion of child abuse or
neglect to the appropriate authorities immediately. Bruises in different stages of healing on
non-bony prominences are a significant red flag for physical abuse. The nurse is not
required to prove abuse, only to report the suspicion to ensure the child’s safety.
3. A pediatric patient is exhibiting signs of septic shock, including tachycardia, bounding
pulses, and warm, flushed skin. Which stage of shock is the child likely experiencing?
A. Decompensated shock
B. Early (warm) septic shock
C. Hypovolemic shock
D. Late (cold) septic shock
Answer: B
Rationale: Early septic shock, also known as ‘warm shock,’ is characterized by peripheral
vasodilation which causes warm, flushed skin and bounding pulses. This occurs as the body
attempts to compensate for the infection by increasing cardiac output. As the condition
progresses, the child will enter the ‘cold’ stage with poor perfusion and hypotension.
,4. An adolescent is admitted to the psychiatric unit with a diagnosis of Major Depressive
Disorder and has started taking a Selective Serotonin Reuptake Inhibitor (SSRI). What is the
most important nursing intervention during the first two weeks of therapy?
A. Monitor for an immediate increase in appetite and weight gain.
B. Encourage the patient to avoid all social interactions.
C. Assess for increased energy levels and suicidal ideation.
D. Stop the medication if the patient feels slightly nauseated.
Answer: C
Rationale: When starting SSRIs, adolescents may experience a surge in energy before their
mood significantly improves, which can increase the risk of acting on suicidal thoughts. The
Black Box warning for SSRIs in this age group highlights the risk of increased suicidality
during the early phase of treatment. Close monitoring and safety planning are essential
nursing responsibilities during this time.
5. A 10-year-old child is brought to the ED after being hit by a car. The child is irritable and
complains of a headache. The nurse notes a widening pulse pressure and bradycardia. What
does this suggest?
A. Hypovolemic shock from internal bleeding
B. Normal physiological response to trauma
C. Increasing intracranial pressure (Cushing’s triad)
D. A localized infection from the injury site
, Answer: C
Rationale: Cushing’s triad consists of bradycardia, widening pulse pressure (increased
systolic BP), and irregular respirations. These signs indicate a significant increase in
intracranial pressure and are a late sign of brain herniation. Immediate intervention is
required to stabilize the child and prevent permanent neurological damage.
6. Which nursing intervention is most appropriate for a child diagnosed with Autism
Spectrum Disorder (ASD) who is hospitalized?
A. Provide a high-stimulation environment to encourage social interaction.
B. Maintain a consistent daily routine and use clear, simple communication.
C. Change the nurse assigned to the child every shift to prevent attachment.
D. Ensure the room is near the nurse’s station with the door open at all times.
Answer: B
Rationale: Children with ASD thrive on predictability and routine, which helps reduce
anxiety in the unfamiliar hospital environment. Clear and simple communication
accommodates their specific processing needs and social communication challenges.
Minimizing sensory triggers and maintaining a calm environment also supports better
coping for the child.
7. A child is admitted with a diagnosis of Munchausen Syndrome by Proxy (MSBP). What
should the nurse prioritize in the care plan?
A. Encouraging the parent to provide all the child’s bedside care.
