HESI: Management of a Pediatric Unit and
Rationale Questions and Verified Answers
Which phone message requires the most immediate response by the nurse manager?
a) A physician who needs information about a suspected child abuse victim admitted to the medical
center the previous day.
b) The daycare center director who reports the onset of a large number of cases of head lice among the
preschool-aged children.
c) A school social worker who is reporting that a local teenager has made death threats and expressed
thoughts of suicide.
d) A teenager who sounds distraught and requests information right away about sexually transmitted
diseases. Correct Answer: c) A school social worker who is reporting that a local teenager has made death
threats and expressed thoughts of suicide.
-
The nurse needs additional information as quickly as possible in order to attempt to deter possible harm
to the teenager or others in the area. This situation has highest priority since the teenager has threatened
harm to self and others.
After the nurse manager responds to the telephone messages, a staff RN consults with the nurse manager
regarding several additional telephone messages from clients.
Which situation requires the most immediate follow-up by the nurse?
a) A mother expressing concern that her baby refuses to take formula, stating the infant's "soft spot"
seems more sunken.
b) A grandmother asking for immunization information, stating her 5-year-old grandchild has never
been immunized.
c) A parent calling to ask if it is necessary to keep her child with a sore throat home from school.
d) A mother stating that she sent her child to school but is concerned about his eye, which is pink and
painful. Correct Answer: a) A mother expressing concern that her baby refuses to take formula, stating
the infant's "soft spot" seems more sunken.
, -
The situation indicates the infant is probably dehydrated, and dehydration can lead to a rapid loss of
physiologic integrity in an infant. The nurse should respond to this situation first.
After advising the nurse regarding the phone calls, the nurse manager learns that initial histories have
been obtained by the intake nurse for several children who have arrived at the clinic and are waiting
with their parents.
Which child requires the most immediate follow-up by a nurse?
a) A 10-month-old with yellow nasal mucous and a fever of 101° F (38.3° C) who is fussy and crying
loudly.
b) A 5-year-old who has started wetting the bed and constantly requests extra snacks and drinks.
c) A 13-year-old who was injured while playing football the previous day and now cannot bear weight
on his foot due to severe pain.
d) A 9-year-old who got hit on the head with a baseball bat and has a bruise behind his ear and clear
nasal discharge. Correct Answer: d) A 9-year-old who got hit on the head with a baseball bat and has a
bruise behind his ear and clear nasal discharge.
-
Bruising behind the ear following a head injury is referred to as a Battle sign, which is an indication of a
basilar skull fracture. Because the clear nasal drainage may be cerebrospinal fluid, this child needs the
most immediate assessment to determine the severity of the head injuries.
The nurse is planning care for the teen with a possible fracture of the foot.
Which task(s) can be assigned to the UAP assisting the nurse? (Select all that apply. One, some, or all
options may be correct.)
a) Palpate for the presence of pedal pulses.
b) Apply a cold pack to the teenager's foot.
c) Explain to the client the difference between a fracture and a sprain.
d) Use a numeric pain scale to assess the teen's pain level.
Rationale Questions and Verified Answers
Which phone message requires the most immediate response by the nurse manager?
a) A physician who needs information about a suspected child abuse victim admitted to the medical
center the previous day.
b) The daycare center director who reports the onset of a large number of cases of head lice among the
preschool-aged children.
c) A school social worker who is reporting that a local teenager has made death threats and expressed
thoughts of suicide.
d) A teenager who sounds distraught and requests information right away about sexually transmitted
diseases. Correct Answer: c) A school social worker who is reporting that a local teenager has made death
threats and expressed thoughts of suicide.
-
The nurse needs additional information as quickly as possible in order to attempt to deter possible harm
to the teenager or others in the area. This situation has highest priority since the teenager has threatened
harm to self and others.
After the nurse manager responds to the telephone messages, a staff RN consults with the nurse manager
regarding several additional telephone messages from clients.
Which situation requires the most immediate follow-up by the nurse?
a) A mother expressing concern that her baby refuses to take formula, stating the infant's "soft spot"
seems more sunken.
b) A grandmother asking for immunization information, stating her 5-year-old grandchild has never
been immunized.
c) A parent calling to ask if it is necessary to keep her child with a sore throat home from school.
d) A mother stating that she sent her child to school but is concerned about his eye, which is pink and
painful. Correct Answer: a) A mother expressing concern that her baby refuses to take formula, stating
the infant's "soft spot" seems more sunken.
, -
The situation indicates the infant is probably dehydrated, and dehydration can lead to a rapid loss of
physiologic integrity in an infant. The nurse should respond to this situation first.
After advising the nurse regarding the phone calls, the nurse manager learns that initial histories have
been obtained by the intake nurse for several children who have arrived at the clinic and are waiting
with their parents.
Which child requires the most immediate follow-up by a nurse?
a) A 10-month-old with yellow nasal mucous and a fever of 101° F (38.3° C) who is fussy and crying
loudly.
b) A 5-year-old who has started wetting the bed and constantly requests extra snacks and drinks.
c) A 13-year-old who was injured while playing football the previous day and now cannot bear weight
on his foot due to severe pain.
d) A 9-year-old who got hit on the head with a baseball bat and has a bruise behind his ear and clear
nasal discharge. Correct Answer: d) A 9-year-old who got hit on the head with a baseball bat and has a
bruise behind his ear and clear nasal discharge.
-
Bruising behind the ear following a head injury is referred to as a Battle sign, which is an indication of a
basilar skull fracture. Because the clear nasal drainage may be cerebrospinal fluid, this child needs the
most immediate assessment to determine the severity of the head injuries.
The nurse is planning care for the teen with a possible fracture of the foot.
Which task(s) can be assigned to the UAP assisting the nurse? (Select all that apply. One, some, or all
options may be correct.)
a) Palpate for the presence of pedal pulses.
b) Apply a cold pack to the teenager's foot.
c) Explain to the client the difference between a fracture and a sprain.
d) Use a numeric pain scale to assess the teen's pain level.
