NSG434 Final Exam Actual Exam Style V2
| NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 2-year-old child with Tetralogy of Fallot experiences a ‘tet spell’ while being examined.
Which nursing action should be performed first?
A. Place the child in a knee-chest position.
B. Administer 100% oxygen via face mask.
C. Prepare to administer morphine sulfate.
D. Begin intravenous fluid resuscitation.
Answer: A
Rationale: The knee-chest position is the priority intervention because it increases
systemic vascular resistance and reduces right-to-left shunting. This improves pulmonary
blood flow and increases oxygenation levels during a hypercyanotic spell. Following this
immediate physical maneuver, oxygen and sedation may be administered as secondary
measures.
2. Which clinical manifestation would the nurse expect to find in an infant with suspected
Coarctation of the Aorta?
A. Blood pressure higher in the arms than in the legs.
B. Cyanosis of the upper extremities but not the lower.
,C. Bounding pedal pulses and weak radial pulses.
D. A continuous machinery-like murmur.
Answer: A
Rationale: Coarctation of the Aorta involves a narrowing of the aorta, typically distal to the
ductus arteriosus, which restricts blood flow to the lower body. This results in high blood
pressure and bounding pulses in the upper extremities and low blood pressure or
weak/absent pulses in the lower extremities. A machinery-like murmur is characteristic of
Patent Ductus Arteriosus, not coarctation.
3. A nurse is caring for a child with Type 1 Diabetes Mellitus who is experiencing
hypoglycemia. Which finding is most consistent with this condition?
A. Deep, rapid Kussmaul respirations.
B. Fruity breath odor.
C. Extreme thirst and polyuria.
D. Diaphoresis and irritability.
Answer: D
Rationale: Hypoglycemia triggers the sympathetic nervous system, leading to symptoms
such as sweating (diaphoresis), tremors, tachycardia, and irritability or confusion. In
contrast, Kussmaul respirations, fruity breath, and extreme thirst are classic indicators of
hyperglycemia or Diabetic Ketoacidosis (DKA). Rapid identification of hypoglycemia is
critical to prevent neuroglycopenic injury.
, 4. When assessing a 10-year-old child with suspected bacterial meningitis, the nurse notes
that when the child’s neck is flexed, the hips and knees also flex. How should the nurse
document this?
A. Positive Kernig sign.
B. Negative Babinski reflex.
C. Nuchal rigidity.
D. Positive Brudzinski sign.
Answer: D
Rationale: The Brudzinski sign is an involuntary flexion of the hips and knees when the
neck is passively flexed, indicating meningeal irritation. The Kernig sign is the inability to
extend the leg when the hip is flexed to 90 degrees. Both are critical indicators of central
nervous system inflammation in pediatric patients.
5. A 9-month-old infant is admitted for moderate dehydration due to vomiting and diarrhea.
Which assessment finding is most characteristic of this level of dehydration?
A. Brisk capillary refill of less than 2 seconds.
B. Slightly sunken fontanel and decreased tears.
C. Increased urine output with low specific gravity.
D. Tented skin turgor and absent pulses.
Answer: B
| NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 2-year-old child with Tetralogy of Fallot experiences a ‘tet spell’ while being examined.
Which nursing action should be performed first?
A. Place the child in a knee-chest position.
B. Administer 100% oxygen via face mask.
C. Prepare to administer morphine sulfate.
D. Begin intravenous fluid resuscitation.
Answer: A
Rationale: The knee-chest position is the priority intervention because it increases
systemic vascular resistance and reduces right-to-left shunting. This improves pulmonary
blood flow and increases oxygenation levels during a hypercyanotic spell. Following this
immediate physical maneuver, oxygen and sedation may be administered as secondary
measures.
2. Which clinical manifestation would the nurse expect to find in an infant with suspected
Coarctation of the Aorta?
A. Blood pressure higher in the arms than in the legs.
B. Cyanosis of the upper extremities but not the lower.
,C. Bounding pedal pulses and weak radial pulses.
D. A continuous machinery-like murmur.
Answer: A
Rationale: Coarctation of the Aorta involves a narrowing of the aorta, typically distal to the
ductus arteriosus, which restricts blood flow to the lower body. This results in high blood
pressure and bounding pulses in the upper extremities and low blood pressure or
weak/absent pulses in the lower extremities. A machinery-like murmur is characteristic of
Patent Ductus Arteriosus, not coarctation.
3. A nurse is caring for a child with Type 1 Diabetes Mellitus who is experiencing
hypoglycemia. Which finding is most consistent with this condition?
A. Deep, rapid Kussmaul respirations.
B. Fruity breath odor.
C. Extreme thirst and polyuria.
D. Diaphoresis and irritability.
Answer: D
Rationale: Hypoglycemia triggers the sympathetic nervous system, leading to symptoms
such as sweating (diaphoresis), tremors, tachycardia, and irritability or confusion. In
contrast, Kussmaul respirations, fruity breath, and extreme thirst are classic indicators of
hyperglycemia or Diabetic Ketoacidosis (DKA). Rapid identification of hypoglycemia is
critical to prevent neuroglycopenic injury.
, 4. When assessing a 10-year-old child with suspected bacterial meningitis, the nurse notes
that when the child’s neck is flexed, the hips and knees also flex. How should the nurse
document this?
A. Positive Kernig sign.
B. Negative Babinski reflex.
C. Nuchal rigidity.
D. Positive Brudzinski sign.
Answer: D
Rationale: The Brudzinski sign is an involuntary flexion of the hips and knees when the
neck is passively flexed, indicating meningeal irritation. The Kernig sign is the inability to
extend the leg when the hip is flexed to 90 degrees. Both are critical indicators of central
nervous system inflammation in pediatric patients.
5. A 9-month-old infant is admitted for moderate dehydration due to vomiting and diarrhea.
Which assessment finding is most characteristic of this level of dehydration?
A. Brisk capillary refill of less than 2 seconds.
B. Slightly sunken fontanel and decreased tears.
C. Increased urine output with low specific gravity.
D. Tented skin turgor and absent pulses.
Answer: B
