NSG434 Final Exam Actual Exam Style V3
| NSG 434 Nursing Care of Children | Grand
Canyon University
1. A nurse is assessing a child with a suspected diagnosis of Acute Lymphoblastic Leukemia
(ALL). Which clinical manifestation should the nurse prioritize?
A. Occasional headaches
B. Increased appetite
C. Improved athletic performance
D. Persistent fever and frequent infections
Answer: D
Rationale: Persistent fever in a child with ALL often indicates an underlying infection due
to neutropenia. Because the bone marrow is overcrowded with immature lymphoblasts, it
cannot produce functional white blood cells. This condition is a medical emergency that
requires immediate assessment and intervention.
2. When caring for a child with Wilms tumor, which action is most important for the nurse to
avoid?
A. Recording intake and output
B. Measuring blood pressure
C. Palpating the abdomen
,D. Providing emotional support
Answer: C
Rationale: Palpating the abdomen of a child with Wilms tumor can cause the encapsulated
tumor to rupture. If the tumor ruptures, cancer cells may spread throughout the abdominal
cavity. The nurse should place a sign at the bedside stating that the abdomen should not be
palpated.
3. A child with Tetralogy of Fallot is experiencing a ‘tet spell’ or hypercyanotic episode. What
is the priority nursing action?
A. Administer oral fluids
B. Place the child in a knee-chest position
C. Apply a warm blanket
D. Perform a deep tracheal suctioning
Answer: B
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt. This maneuver improves pulmonary blood flow and
increases oxygen saturation levels. After positioning the child, the nurse should also
prepare to administer oxygen and morphine if needed.
4. A 2-year-old child is diagnosed with Nephrotic Syndrome. Which clinical finding should the
nurse expect to observe?
A. Gross hematuria
, B. Severe generalized edema
C. Hypotension
D. Weight loss
Answer: B
Rationale: Nephrotic syndrome is characterized by massive proteinuria, which leads to
low serum albumin levels. The resulting decrease in osmotic pressure causes fluid to shift
into the interstitial spaces, leading to severe edema. The nurse must monitor daily weights
and abdominal girth to track fluid retention.
5. Which of the following is a key nursing intervention for a child immediately following a
cleft lip repair?
A. Place the child in a prone position
B. Apply elbow restraints to prevent touching the suture line
C. Encourage the child to use a straw
D. Avoid any cleaning of the surgical site
Answer: B
Rationale: Elbow restraints, often called ‘Logan bows’ or ‘no-nos,’ are essential to prevent
the child from rubbing or picking at the fresh sutures. Protecting the integrity of the suture
line is the highest priority to ensure proper healing and minimize scarring. The nurse must
remove the restraints periodically to assess skin integrity and provide range of motion.
| NSG 434 Nursing Care of Children | Grand
Canyon University
1. A nurse is assessing a child with a suspected diagnosis of Acute Lymphoblastic Leukemia
(ALL). Which clinical manifestation should the nurse prioritize?
A. Occasional headaches
B. Increased appetite
C. Improved athletic performance
D. Persistent fever and frequent infections
Answer: D
Rationale: Persistent fever in a child with ALL often indicates an underlying infection due
to neutropenia. Because the bone marrow is overcrowded with immature lymphoblasts, it
cannot produce functional white blood cells. This condition is a medical emergency that
requires immediate assessment and intervention.
2. When caring for a child with Wilms tumor, which action is most important for the nurse to
avoid?
A. Recording intake and output
B. Measuring blood pressure
C. Palpating the abdomen
,D. Providing emotional support
Answer: C
Rationale: Palpating the abdomen of a child with Wilms tumor can cause the encapsulated
tumor to rupture. If the tumor ruptures, cancer cells may spread throughout the abdominal
cavity. The nurse should place a sign at the bedside stating that the abdomen should not be
palpated.
3. A child with Tetralogy of Fallot is experiencing a ‘tet spell’ or hypercyanotic episode. What
is the priority nursing action?
A. Administer oral fluids
B. Place the child in a knee-chest position
C. Apply a warm blanket
D. Perform a deep tracheal suctioning
Answer: B
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt. This maneuver improves pulmonary blood flow and
increases oxygen saturation levels. After positioning the child, the nurse should also
prepare to administer oxygen and morphine if needed.
4. A 2-year-old child is diagnosed with Nephrotic Syndrome. Which clinical finding should the
nurse expect to observe?
A. Gross hematuria
, B. Severe generalized edema
C. Hypotension
D. Weight loss
Answer: B
Rationale: Nephrotic syndrome is characterized by massive proteinuria, which leads to
low serum albumin levels. The resulting decrease in osmotic pressure causes fluid to shift
into the interstitial spaces, leading to severe edema. The nurse must monitor daily weights
and abdominal girth to track fluid retention.
5. Which of the following is a key nursing intervention for a child immediately following a
cleft lip repair?
A. Place the child in a prone position
B. Apply elbow restraints to prevent touching the suture line
C. Encourage the child to use a straw
D. Avoid any cleaning of the surgical site
Answer: B
Rationale: Elbow restraints, often called ‘Logan bows’ or ‘no-nos,’ are essential to prevent
the child from rubbing or picking at the fresh sutures. Protecting the integrity of the suture
line is the highest priority to ensure proper healing and minimize scarring. The nurse must
remove the restraints periodically to assess skin integrity and provide range of motion.
