Chapter 14. Critical Care
1. A child in the ICU exhibits tachycardia, tachypnea, hypertension, and low pulse
pressure in the extremities. Which of these signs is the best indicator of inadequate
perfusion of blood?
A) Tachycardia
B) Tachypnea
C) Hypertension
D) Low pulse pressure
2. A 12-month-old child is admitted to the ICU after being found abandoned in a hot car.
The child is responsive, but the nurse notices that the anterior fontanelle of the child is
sunken. Which of the following conditions should the nurse suspect in this
situation? A) Dehydration
B) Increased intracranial pressure
C) Fluid overload
D) Hypertension
3. An ICU nurse, in testing the reflexes of a 3-month-old baby girl, strokes the lateral
aspect of the sole of the foot to test for possible nerve damage. In response, the child
fans her
toes and dorsiflexes her big toe. What is the name of this reflex, and is the childs
response
normal?
A) Moro reflex; abnormal
B) Rooting reflex; normal
, C) Grasp reflex; abnormal
D) Babinski reflex; normal
4. A nurse in the ICU observes paradoxical irritability, meningeal irritability, and
nuchal rigidity in a 5-year-old girl. She suspects meningitis. What other finding or
findings would support this belief? Select all that apply.
A) Positive Babinski reflex
B) Positive Moro reflex
C) Positive Brudzinskis sign
D) Positive Kernigs sign
5. A newborn baby involved in an auto accident has been admitted to the ICU and is
currently being assessed by a nurse in a drafty, cool room. The nurse notes mottling on
the infants skin, a progression of coolness toward the trunk, peripheral cyanosis,
normal blood pressure, low pulse pressure, and tachycardia. Given the circumstances,
which of the following are reliable signs that the infant is in shock? Select all that
apply.
A) Mottled skin
B) Progression of coolness toward the trunk
C) Peripheral cyanosis
D) Normal blood pressure
E) Low pulse pressure
F) Tachycardia
6. A nurse working with an infant patient observes that the child, who has a nasogastric
tube, is grunting on expiration, wheezing, and seesaw breathing. The nurse
recognizes that the infant is most likely experiencing which condition?
A) Respiratory distress due to obstructed nasal passages
B) Respiratory arrest due to obstruction of the glottis
C) Epileptic seizure due to overstimulation
D) Shock due to loss of blood
7. A 2-year-old is admitted to the ICU due to severe dehydration. The mother of the child
is distraught and feels guilty that she took a long walk with her child in the sun earlier in
the day. She said that she and the rest of the family had no issues with dehydration.
What would be the best response for the nurse to give the mother?
A) Children his age should have limited sun exposure and should be covered
with sunscreen.
1. A child in the ICU exhibits tachycardia, tachypnea, hypertension, and low pulse
pressure in the extremities. Which of these signs is the best indicator of inadequate
perfusion of blood?
A) Tachycardia
B) Tachypnea
C) Hypertension
D) Low pulse pressure
2. A 12-month-old child is admitted to the ICU after being found abandoned in a hot car.
The child is responsive, but the nurse notices that the anterior fontanelle of the child is
sunken. Which of the following conditions should the nurse suspect in this
situation? A) Dehydration
B) Increased intracranial pressure
C) Fluid overload
D) Hypertension
3. An ICU nurse, in testing the reflexes of a 3-month-old baby girl, strokes the lateral
aspect of the sole of the foot to test for possible nerve damage. In response, the child
fans her
toes and dorsiflexes her big toe. What is the name of this reflex, and is the childs
response
normal?
A) Moro reflex; abnormal
B) Rooting reflex; normal
, C) Grasp reflex; abnormal
D) Babinski reflex; normal
4. A nurse in the ICU observes paradoxical irritability, meningeal irritability, and
nuchal rigidity in a 5-year-old girl. She suspects meningitis. What other finding or
findings would support this belief? Select all that apply.
A) Positive Babinski reflex
B) Positive Moro reflex
C) Positive Brudzinskis sign
D) Positive Kernigs sign
5. A newborn baby involved in an auto accident has been admitted to the ICU and is
currently being assessed by a nurse in a drafty, cool room. The nurse notes mottling on
the infants skin, a progression of coolness toward the trunk, peripheral cyanosis,
normal blood pressure, low pulse pressure, and tachycardia. Given the circumstances,
which of the following are reliable signs that the infant is in shock? Select all that
apply.
A) Mottled skin
B) Progression of coolness toward the trunk
C) Peripheral cyanosis
D) Normal blood pressure
E) Low pulse pressure
F) Tachycardia
6. A nurse working with an infant patient observes that the child, who has a nasogastric
tube, is grunting on expiration, wheezing, and seesaw breathing. The nurse
recognizes that the infant is most likely experiencing which condition?
A) Respiratory distress due to obstructed nasal passages
B) Respiratory arrest due to obstruction of the glottis
C) Epileptic seizure due to overstimulation
D) Shock due to loss of blood
7. A 2-year-old is admitted to the ICU due to severe dehydration. The mother of the child
is distraught and feels guilty that she took a long walk with her child in the sun earlier in
the day. She said that she and the rest of the family had no issues with dehydration.
What would be the best response for the nurse to give the mother?
A) Children his age should have limited sun exposure and should be covered
with sunscreen.
