ENPC 4th Edition: Practice Test
Question and answer 100% solved
1. A preschooler has a small laceration that requires 2 stitches. The nurse covers the
wound with a bandage knowing that it will comfort the child to have it covered. What is
the developmental reason for this intervention?
A.) Preschoolers are magical thinkers and imagine bandages keep their insides from
coming out.
B.) Preschoolers fear physical disability and believe a bandage will prevent disability.
C.) Preschoolers explore orally and will likely chew or suck on the stitches if left
uncovered.
D.) Preschoolers are concerned with body image and don't want to appear different than
peers. - correct answer A.) Preschoolers are magical thinkers and imagine bandages
keep their insides from coming out.
Rationale: Preschoolers are magical and illogical thinkers and have difficulty
distinguishing fantasy from reality. They have misconceptions about illness, injury, and
bodily functions. For example, they perceive that if their skin is cut, they fear their
insides will leak out. Covering a wound with a bandage helps them with this fear.
2. 7-month-old presents to the emergency department with a complaint of fever.
Assessment reveals a patent airway and slight cyanosis around his lips and nail beds.
He is alert and interactive. His vital signs are 38.5 C (101.3F), HR 134, RR 32, BP 78/54
mm Hg, and Spo2 84%. The nurse notes a healed surgical scar on his chest. Based on
this assessment, what is the nurse's priority?
A.) Administer ibuprofen to treat the fever.
B.) Begin oxygen via a nonrebreather mask.
C.) Obtain a surgical history.
D.) Ask if the Spo2 is normal for him. - correct answer D.) Ask if the Spo2 is normal for
him.
Rationale: Children with special healthcare needs may present differently than other
children, but these differences may be normal. The surgical scar on the chest is likely
from a congenital heart defect repair. The mother's chief complaint is the fever, not the
color, pulse oximetry, or the respiratory distress. This may be because these aspects of
his assessment are normal. The intact mental status is also a sign that he has adapted
to lowers oxygen saturation's. The child's baseline must come from the caregiver before
any intervention.
3. An 11-year-old presents to the emergency department with a complaint of hitting his
head while playing soccer. The nurse enters the room and performs an across-the-room
assessment. He is staring at the wall. He has no increased work of breathing, and his
color is pink. Using the pediatric assessment triangle (PAT), what classification will the
nurse assign?
,A.) Well
Rationale: In using the PAT, there is not a Well category. A child may appear well and
without disruption in any of the three components of the PAT but is still designated sick.
All pediatric patients presenting to the emergency department are considered sick
simply based on the fact that the caregiver was concerned enough to bring the child to
the emergency department (p. 54).
B.) Sick
Rationale: If there is no disruption in any of the three components of the PAT, a
pediatric patient is considered sick. This child has an abnormality in one of the three. He
is staring at the wall, which is a disruption in the general appearance component (p. 54).
C.) Sicker
Rationale: This child has a disruption in one of the three components of the PAT. He is
staring at the wall, which is a disruption in the general appearance component. It may
be that he is anxious and fearful about the experience, but it could be a result of the
head injury. More assessment is required (p. 54).
D.) Sickest
Rationale: If there are disruptions in two or more of the three components of the PAT, a
pediatric patient is considered sickest and needs immediate evaluation and intervention.
This child has an abnormality in one of the
three components (p. 54). - correct answer C.) Sicker
Rationale: This child has a disruption in one of the three components of the PAT. He is
staring at the wall, which is a disruption in the general appearance component. It may
be that he is anxious and fearful about the experience, but it could be a result of the
head injury. More assessment is required (p. 54).
4. The pediatric prioritization process components include the focused assessment,
focused history, acuity rating decision and:
A.) the pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization process include the
pediatric assessment triangle (PAT), the focused assessment (objective data), the
focused history (subjective data), and the assignment of the triage acuity rating. These
components ensure enough information is rapidly gathered and used to provide
appropriate care and timely interventions for pediatric patients (p. 52).
B.) developmental characteristics.
Rationale: Developmental characteristics are incorporated into each component of the
pediatric prioritization
process but do not constitute a separate element (p. 52).
C.) head-to-toe assessment.
Rationale: The head-to-toe assessment is part of the focused assessment but not a
separate element (p. 52).
D.) life-saving interventions.
Rationale: Life-saving interventions should be performed at any point throughout the
prioritization process as
life threats are identified (p. 52) - correct answer A.) The pediatric assessment triangle
(PAT).
, Rationale: The four components of the pediatric prioritization process include the
pediatric assessment triangle (PAT), the focused assessment (objective data), the
focused history (subjective data), and the assignment of the triage acuity rating. These
components ensure enough information is rapidly gathered and used to provide
appropriate care and timely interventions for pediatric patients (p. 52).
5. A 2-year-old is brought to the emergency department by her father when he found
her face down in the pool. She remains unresponsive and is breathing shallowly and
slowly. Her color is pale. What is the priority?
A.) Administer 100% oxygen
Rationale: The primary assessment in a trauma patient begins with immobilization of the
cervical spine while opening the airway. The remainder of the primary assessment
interventions including oxygenation is performed after cervical spinal immobilization (p.
64).
B.) Immobilize the cervical spine
Rationale: Any unresponsive child found in a pool must be assumed to be a trauma
patient and with a cervical spinal injury until proven otherwise. The primary assessment
in a trauma patient begins with immobilization of the cervical spine while opening the
airway. The remainder of the primary assessment interventions, including inserting an
airway, oxygenation, and ventilation, is performed after cervical spinal immobilization (p.
64).
C.) Begin bag-mask ventilation
Rationale: The primary assessment in a trauma patient begins with immobilization of the
cervical spine while opening the airway. The remainder of the primary assessment
interventions, including ventilation, is performed after cervical spinal immobilization (p.
64).
D.) Insert an oral airway
Rationale: The primary assessment in a trauma patient begins with immobilization of the
cervical spine while opening the airway. The remainder of the primary assessment
interventions, including inserting an airway, if
needed, is performed after cervical spinal immobilization (p. 64). - correct answer B.)
Immobilize the cervical spine.
Rationale: Any unresponsive child found in a pool must be assumed to be a trauma
patient and with a cervical spinal injury until proven otherwise. The primary assessment
in a trauma patient begins with immobilization of the cervical spine while opening the
airway. The remainder of the primary assessment interventions, including inserting an
airway, oxygenation, and ventilation, is performed after cervical spinal immobilization (p.
64).
6. A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal
alignment, padding should be placed under which area?
a. Shoulders
Rationale: The younger child has a larger head proportionally to the body and when
lying supine is naturally in a position of cervical flexion. Padding under the shoulders or
Question and answer 100% solved
1. A preschooler has a small laceration that requires 2 stitches. The nurse covers the
wound with a bandage knowing that it will comfort the child to have it covered. What is
the developmental reason for this intervention?
A.) Preschoolers are magical thinkers and imagine bandages keep their insides from
coming out.
B.) Preschoolers fear physical disability and believe a bandage will prevent disability.
C.) Preschoolers explore orally and will likely chew or suck on the stitches if left
uncovered.
D.) Preschoolers are concerned with body image and don't want to appear different than
peers. - correct answer A.) Preschoolers are magical thinkers and imagine bandages
keep their insides from coming out.
Rationale: Preschoolers are magical and illogical thinkers and have difficulty
distinguishing fantasy from reality. They have misconceptions about illness, injury, and
bodily functions. For example, they perceive that if their skin is cut, they fear their
insides will leak out. Covering a wound with a bandage helps them with this fear.
2. 7-month-old presents to the emergency department with a complaint of fever.
Assessment reveals a patent airway and slight cyanosis around his lips and nail beds.
He is alert and interactive. His vital signs are 38.5 C (101.3F), HR 134, RR 32, BP 78/54
mm Hg, and Spo2 84%. The nurse notes a healed surgical scar on his chest. Based on
this assessment, what is the nurse's priority?
A.) Administer ibuprofen to treat the fever.
B.) Begin oxygen via a nonrebreather mask.
C.) Obtain a surgical history.
D.) Ask if the Spo2 is normal for him. - correct answer D.) Ask if the Spo2 is normal for
him.
Rationale: Children with special healthcare needs may present differently than other
children, but these differences may be normal. The surgical scar on the chest is likely
from a congenital heart defect repair. The mother's chief complaint is the fever, not the
color, pulse oximetry, or the respiratory distress. This may be because these aspects of
his assessment are normal. The intact mental status is also a sign that he has adapted
to lowers oxygen saturation's. The child's baseline must come from the caregiver before
any intervention.
3. An 11-year-old presents to the emergency department with a complaint of hitting his
head while playing soccer. The nurse enters the room and performs an across-the-room
assessment. He is staring at the wall. He has no increased work of breathing, and his
color is pink. Using the pediatric assessment triangle (PAT), what classification will the
nurse assign?
,A.) Well
Rationale: In using the PAT, there is not a Well category. A child may appear well and
without disruption in any of the three components of the PAT but is still designated sick.
All pediatric patients presenting to the emergency department are considered sick
simply based on the fact that the caregiver was concerned enough to bring the child to
the emergency department (p. 54).
B.) Sick
Rationale: If there is no disruption in any of the three components of the PAT, a
pediatric patient is considered sick. This child has an abnormality in one of the three. He
is staring at the wall, which is a disruption in the general appearance component (p. 54).
C.) Sicker
Rationale: This child has a disruption in one of the three components of the PAT. He is
staring at the wall, which is a disruption in the general appearance component. It may
be that he is anxious and fearful about the experience, but it could be a result of the
head injury. More assessment is required (p. 54).
D.) Sickest
Rationale: If there are disruptions in two or more of the three components of the PAT, a
pediatric patient is considered sickest and needs immediate evaluation and intervention.
This child has an abnormality in one of the
three components (p. 54). - correct answer C.) Sicker
Rationale: This child has a disruption in one of the three components of the PAT. He is
staring at the wall, which is a disruption in the general appearance component. It may
be that he is anxious and fearful about the experience, but it could be a result of the
head injury. More assessment is required (p. 54).
4. The pediatric prioritization process components include the focused assessment,
focused history, acuity rating decision and:
A.) the pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization process include the
pediatric assessment triangle (PAT), the focused assessment (objective data), the
focused history (subjective data), and the assignment of the triage acuity rating. These
components ensure enough information is rapidly gathered and used to provide
appropriate care and timely interventions for pediatric patients (p. 52).
B.) developmental characteristics.
Rationale: Developmental characteristics are incorporated into each component of the
pediatric prioritization
process but do not constitute a separate element (p. 52).
C.) head-to-toe assessment.
Rationale: The head-to-toe assessment is part of the focused assessment but not a
separate element (p. 52).
D.) life-saving interventions.
Rationale: Life-saving interventions should be performed at any point throughout the
prioritization process as
life threats are identified (p. 52) - correct answer A.) The pediatric assessment triangle
(PAT).
, Rationale: The four components of the pediatric prioritization process include the
pediatric assessment triangle (PAT), the focused assessment (objective data), the
focused history (subjective data), and the assignment of the triage acuity rating. These
components ensure enough information is rapidly gathered and used to provide
appropriate care and timely interventions for pediatric patients (p. 52).
5. A 2-year-old is brought to the emergency department by her father when he found
her face down in the pool. She remains unresponsive and is breathing shallowly and
slowly. Her color is pale. What is the priority?
A.) Administer 100% oxygen
Rationale: The primary assessment in a trauma patient begins with immobilization of the
cervical spine while opening the airway. The remainder of the primary assessment
interventions including oxygenation is performed after cervical spinal immobilization (p.
64).
B.) Immobilize the cervical spine
Rationale: Any unresponsive child found in a pool must be assumed to be a trauma
patient and with a cervical spinal injury until proven otherwise. The primary assessment
in a trauma patient begins with immobilization of the cervical spine while opening the
airway. The remainder of the primary assessment interventions, including inserting an
airway, oxygenation, and ventilation, is performed after cervical spinal immobilization (p.
64).
C.) Begin bag-mask ventilation
Rationale: The primary assessment in a trauma patient begins with immobilization of the
cervical spine while opening the airway. The remainder of the primary assessment
interventions, including ventilation, is performed after cervical spinal immobilization (p.
64).
D.) Insert an oral airway
Rationale: The primary assessment in a trauma patient begins with immobilization of the
cervical spine while opening the airway. The remainder of the primary assessment
interventions, including inserting an airway, if
needed, is performed after cervical spinal immobilization (p. 64). - correct answer B.)
Immobilize the cervical spine.
Rationale: Any unresponsive child found in a pool must be assumed to be a trauma
patient and with a cervical spinal injury until proven otherwise. The primary assessment
in a trauma patient begins with immobilization of the cervical spine while opening the
airway. The remainder of the primary assessment interventions, including inserting an
airway, oxygenation, and ventilation, is performed after cervical spinal immobilization (p.
64).
6. A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal
alignment, padding should be placed under which area?
a. Shoulders
Rationale: The younger child has a larger head proportionally to the body and when
lying supine is naturally in a position of cervical flexion. Padding under the shoulders or
