RN pediatric nursing online practice 2023 a

Table of Contents

Here is the comprehensive study guide for the RN Pediatric Nursing Online Practice 2023 A exam.

This table includes the full text of every question, the complete answer(s), and a detailed rationale for each, derived directly from the source material to assist with your revision.

#	Question / Scenario	Correct Answer / Action	Detailed Rationale & Study Notes
1	A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?	Administer epinephrine IM	Urgent vs. Non-Urgent Priority Setting: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. Pathophysiology: During an anaphylactic reaction, massive histamine release causes bronchoconstriction (closing of airways) and systemic vasodilation (widening of blood vessels). This is a medical emergency because ultimately it causes decreased blood return to the heart and respiratory collapse. Epinephrine acts quickly to reverse these specific life-threatening mechanisms. ¹
2	A nurse in a pediatric emergency department is planning care for an adolescent. Based on the information in the adolescent’s medical record, which of the following actions should the nurse plan to take? (Select all that apply)	1. Apply supplemental oxygen 2. Prepare for chest tube insertion 3. Monitor the child’s oxygen saturation	1. Supplemental Oxygen: According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. The adolescent’s oxygen saturation level is decreasing, indicating hypoxia. The nurse must administer oxygen to correct this. 2. Chest Tube: A pneumothorax is the presence of air in the pleural cavity, resulting in decreased lung expansion. Symptoms include dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt intervention, such as placing a chest tube to remove air/fluid and allow the lung to re-expand. 3. Monitor Saturation: Because the child is in acute respiratory distress, continuous monitoring is necessary to determine if the child is responding to treatment. ²
3	A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take?	Monitor the child’s oxygen saturation	Safety & Monitoring: Epiglottitis is a medical emergency involving inflammation of the epiglottis that can block the airway. The nurse should monitor the child’s oxygen saturation level because the child is experiencing acute respiratory distress. Continuous monitoring is necessary to determine if the child is maintaining oxygenation and responding to treatment. ³
4	A nurse is providing teaching about play activities for social development to the guardians of a preschooler. Which of the following play activities should the nurse recommend for the child?	Playing dress-up	Developmental Milestones (Preschool): The nurse should instruct the guardians that at the preschool age, play should focus on social, mental, and physical development. “Dramatic play” or playing dress-up is a recommended activity that fosters imagination and social role-playing, which are critical for this age group. ⁴
5	A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first?	A school-age child who has sickle cell anemia and reports decreased vision in the left eye	Urgent vs. Non-Urgent Priority Setting: The priority finding is a report of decreased vision in the left eye in a patient with sickle cell anemia. This finding indicates a vaso-occlusive crisis occurring in the eye (retinopathy), which threatens permanent vision loss. This must be reported to the provider immediately to preserve sight. ⁵
6	A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching?	“Brush the child’s teeth after giving the medication.”	Medication Administration Safety: Digoxin elixir for pediatric patients often comes as a sweetened liquid to enhance palatability. The nurse should instruct parents to brush the child’s teeth after administration to prevent tooth decay caused by the high sugar content of the medication. ⁶
7	A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area?	Zinc oxide	Skin Integrity: Diaper dermatitis is an inflammatory skin disorder caused by contact with irritants such as urine, feces, soap, or friction. It presents as scaling, blisters, or papules with erythema. Zinc oxide provides a protective barrier against these irritants, allowing the skin to heal. ⁷
8	A nurse is caring for a client who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Order the steps)	1. Turn off the IV pump 2. Occlude the IV tubing 3. Remove the tape securing the catheter 4. Apply pressure over the catheter insertion site	Procedural Safety: 1. Turn off pump: Stops the flow of fluid. 2. Occlude tubing: Prevents backflow or fluid mess while manipulating the line. 3. Remove tape: Frees the catheter for removal. 4. Apply pressure: Immediately upon removal to prevent bleeding or hematoma formation. ⁸
9	A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex.	[Hot Spot Selection: The Antecubital Fossa]	Neurological Assessment: To elicit the biceps reflex, the nurse should tap the biceps tendon, which is located in the antecubital fossa (the inner aspect of the elbow). This tests the integrity of the C5 and C6 nerve roots. ⁹
10	A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?	Screen the child’s visitors for indications of infection	Infection Control: A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming and life-threatening infection. Screening visitors prevents the introduction of pathogens into the child’s environment. ¹⁰
11	A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?	“Shake the medication prior to administration.”	Medication Administration: Nystatin acts as a suspension. The nurse should instruct the parent to shake the bottle vigorously prior to administration to ensure the medication particles are dispersed evenly throughout the liquid, ensuring the child receives the correct dosage. ¹¹
12	A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding of the teaching?	“Mononucleosis is caused by an infection with the Epstein-Barr virus.”	Disease Pathophysiology: Infectious mononucleosis is a mildly contagious illness that occurs sporadically or in groups. The primary causative agent is the Epstein-Barr virus (EBV). ¹²¹²¹²¹²
13	A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?	Provide small, frequent meals for the child	Nutritional Support in Heart Failure: Children with heart failure have a high metabolic rate due to poor cardiac function and increased work of breathing. Providing small, frequent meals helps conserve energy (eating large meals is tiring) while ensuring the child meets their high caloric needs. ¹³¹⁴
14¹⁵	A nurse is providing anticipatory guidance to the guardian of a toddler. Which of the following expected beh¹⁶avior characteristics of toddlers should the nurse include?	Expresses likes and dislikes	Developmental Theory: Toddlerhood is the time when a child develops autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. Expressing strong likes/dislikes is expected. Guardians should allow some control but set limits so the child learns to control their actions. ¹⁷
15	A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse’s priority?	Disease process	Safety & Infection Control: The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, determining the child’s disease process (is it contagious? does the child need protective isolation?) is the priority consideration for room assignment. ¹⁸
16	A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?	Administer an analgesic to the child	Pain Management: Hydrotherapy for wound debridement is an extremely painful procedure. It requires analgesia and/or sedation. Controlling pain reduces physiological stress demands on the body and decreases the likelihood of the child developing depression or PTSD. ¹⁹
17	A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?	“I should keep my child indoors when I mow the yard.”	Trigger Avoidance: The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when pollen counts are high. Guarding against exposure to known allergens found outdoors (grass, tree, weed pollen, dust) decreases the frequency of asthma attacks. ²⁰
18	A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of non-heme iron?	1/2 cup raisins	Nutritional Management: Raisins are a rich source of non-heme iron. The nurse should encourage the adolescent to eat raisins to help replenish iron stores and treat the anemia. ²¹
19	A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis (JIA). Which of the following instructions should the nurse include in the teaching?	“Encourage the child to perform independent self-care.”	Promotion of Independence & Mobility: Encouraging independent self-care minimizes the child’s pain while maximizing mobility and joint function. Praising efforts for independence also increases the child’s self-esteem, which can be impacted by chronic illness. ²²
20	A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?	Apply topical analgesic cream to the site 1 hr prior to the procedure	Procedural Pain Management: Applying a topical analgesic (like EMLA cream) to the lumbar site 1 hour prior to the procedure decreases the adolescent’s pain when the lumbar needle is inserted, facilitating better coping and cooperation. ²³
21	Case Study (Lead Poisoning): A nurse in the outpatient pediatric clinic is caring for a 2-year-old child. Highlight the findings that require follow-up.²⁴	1. Pale pink mucous membranes²⁵ 2. Living in an older urban house that is being renovated²⁶ 3. Parent’s report that toddler seems less active and gets tired more quick²⁷ly	Recognizing Cues: These findings are associated with lead poisoning. * Pale pink membranes/Fatigue: Manifestations of anemia, which is a direct result of lead interfering with heme synthesis. * Renovation: Older urban homes are a common source of lead paint; renovation aerosolizes the lead particles, creating a high inhalation/ingestion risk. ²⁸
22	Case Study (Lead Poisoning): When analyzing cues, the nurse should identify that the child is at risk for developing which conditions due to elevated blood lead level?	1. Intellectual deficits 2. Decreased kidney function	Analyzing Cues: * Intellectual deficits: Lead increases membrane permeability in brain tissue, leading to increased intracranial pressure, tissue ischemia, and atrophy. This results in decreased IQ and cognitive impairment. * Kidney function: Lead damages the proximal tubules of the kidneys, causing reversible or irreversible dysfunction. ²⁹
23	Case Study (Lead Poisoning): Complete the sentence: The nurse should first address the child’s ______, followed by the child’s ______.	First: Elevated Blood Lead Level (BLL) Followed by: Hemoglobin	Prioritizing Hypotheses: Using the framework of safety/risk reduction, the elevated BLL is the root cause. It presents an immediate risk for long-term cognitive impairment and must be addressed first. Lead interferes with heme synthesis, causing the anemia (low hemoglobin); therefore, addressing the lead level first will cause the hemoglobin to improve. ³⁰
24	Case Study (Lead Poisoning): For each potential provider prescription, specify if it is Anticipated or Contraindicated.	1. Succimer: Anticipated 2. Ferrous Sulfate: Anticipated 3. Consult Dietitian: Anticipated 4. Consult Social Services: Anticipated	Generating Solutions: * Succimer: A chelating agent used for BLL >45 mcg/dL. * Ferrous Sulfate: Treats the anemia caused by lead. * Social Services: Assists with finding safe housing away from renovations. * Dietitian: Assists in providing meals high in iron/calcium and low in fat (which reduces lead absorption). ³¹
25	Case Study (Lead Poisoning): The nurse is providing discharge teaching. Which of the following information should the nurse include? (Select all that apply)	1. Open the succimer capsule and sprinkle on 1 tsp of applesauce. 2. Use a wet cloth to dust. 3. Give ferrous sulfate elixir using a straw. 4. Offer orange juice when administering ferrous sulfate. 5. Monitor number of wet diapers. 6. Prevent playing in soil.	Taking Action: * Administration: 2-year-olds cannot swallow pills; sprinkling on food aids adherence. * Dusting: Wet cloths prevent spreading lead dust into the air. * Straw: Iron stains teeth; a straw bypasses them. * Orange Juice: Vitamin C (ascorbic acid) increases iron absorption. * Hydration: Hydration prevents renal toxicity from the chelating agent (monitor wet diapers). * Soil: Soil near old homes is likely contaminated. ³²
26	Case Study (Lead Poisoning): Which of the following conditions are improving since the child’s visit 1 month ago? (Select 4)	1. Blood Lead Level (BLL) 2. Amount of glucose in urine 3. Exposure to lead 4. Nutritional status	Evaluating Outcomes: * BLL: Has decreased, indicating chelation is working. * Urine Glucose: Decreased glycosuria shows the proximal kidney tubules are healing. * Exposure: The family moved out of the renovation zone. * Nutrition: Child is eating better and gaining weight. ³³
27	A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?	Hematocrit 28%	Diagnostic Interpretation: The expected reference range for hematocrit in a school-age child is 32% to 44%. A level of 28% is low, indicating anemia. This reduced oxygen-carrying capacity explains the child’s symptoms of fatigue, lightheadedness, tachycardia, dyspnea, and pallor. ³⁴
28	A nurse in a provider’s office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?	Withhold the measles, mumps, and rubella (MMR) vaccine	Contraindications: The nurse should recognize that a severe allergy to neomycin (indicated in the “Exhibit” tab in the actual exam, implied here by rationale) with an anaphylactic reaction is a contraindication for the MMR vaccine. Severe allergies to eggs or gelatin are also contraindications. ³⁵
29	A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child’s respirations, which of the following actions should the nurse take next?	Initiate IV access	ABC Priority Framework: Using the Airway, Breathing, Circulation approach: 1. Airway/Breathing: Already stabilized in the prompt. 2. Circulation: The next priority is to establish IV access to maintain/restore the child’s circulatory volume (fluid resuscitation). ³⁶
30	A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?	Serum creatinine 3.0 mg/dL	Organ Rejection Indicators: Creatinine is a byproduct of protein metabolism excreted by the kidneys. An elevated level indicates the kidney is not filtering properly. The expected range for an adolescent is 0.4 to 1.0 mg/dL. A level of 3.0 mg/dL is significantly elevated and suggests rejection/failure. ³⁷
31	A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?	Schedule the toddler for a yearly re-screening	Lead Protocols: While any lead exposure is concerning, a level of 4 mcg/dL does not typically require chelation (used for >45). The standard of care is to educate the family on prevention and schedule a re-screening in 1 year to monitor the level. ³⁸
32	A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney’s point?	[Hot Spot Selection: Right Lower Quadrant]	Anatomical Landmarks: McBurney’s point is located in the Right Lower Quadrant (RLQ), about two-thirds of the way between the umbilicus and the anterosuperior iliac spine. This is the classic area of tenderness for appendicitis. ³⁹
33	A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?	Presence of strabismus	Visual Development: Strabismus (crossing of the eyes) is normal in newborns but typically disappears by 3 to 4 months of age. If it persists at 6 months, it can lead to amblyopia (blindness) if not corrected. It requires a referral. ⁴⁰
34	A nurse is caring for a preschooler who has neutropenia. Which of the following statements should the nurse make to the child’s guardians?	“Avoid using your child’s daycare center.”	Neutropenic Precautions: Neutropenia involves a low count of neutrophils (white blood cells), making the child immunocompromised and highly susceptible to infection. Guardians must avoid places where large groups gather, such as daycare centers, to reduce exposure to pathogens. ⁴¹
35	A nurse is assessing an adolescent who received a sodium polystyrene sulfonate (Kayexalate) enema. Which of the following findings indicates effectiveness of the medication?	Serum potassium level 4.1 mEq/L	Medication Outcomes: Sodium polystyrene sulfonate is used to treat hyperkalemia (high potassium) by exchanging sodium ions for potassium ions in the intestine, which are then excreted. A potassium level within the normal range (3.4 to 4.7 mEq/L) proves the medication was effective.
36	A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?	Initiate droplet precautions for the child	Infection Control: Pertussis (Whooping Cough) is transmitted through contact with infected large-droplet nuclei suspended in the air when the child coughs/sneezes. Droplet precautions (mask, private room) are required to prevent transmission.
37	A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?	“I will monitor my child’s number of wet diapers.”	Home Monitoring of Hydration: Monitoring the number of wet diapers per day is the most effective and practical way for a parent to assess if the child is producing adequate urine output and maintaining hydration status at home. ⁴²
38	A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus (DI)?⁴³	Sodium 155 mEq/L⁴⁴	Pathophysiology of DI:⁴⁵ Head injury can cause pituitary hypofunction, leading to a deficiency of ADH (Antidiuretic Hormone).⁴⁶ Without ADH, the child excretes massive amounts of dilute urine (polyuria). This loss of free water leads to dehydration and hypernatremia (Sodium >145 mEq/L). ⁴⁷
39	A nurse is caring for a school-age child who is in Buck’s traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take?	Assess peripheral pulses once every 4 hr	Traction Care: Buck’s traction immobilizes the limb but can compromise circulation. The nurse must provide frequent neurovascular checks (at least every 4 hours) to monitor for signs of impairment: cyanosis, edema, pain, absent pulses, or tingling. ⁴⁸
40	A charge nurse is preparing an in-service about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?	Symmetric burns of the lower extremities	Signs of Abuse: Symmetric burns (e.g., “stocking” burns from dipping feet in hot water) are characteristic of intentional injury. Accidental burns are usually asymmetrical (splash patterns). Patterned burns (cigarettes, iron shapes) are also indicators. ⁴⁹
41	A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include?	The child should be able to stand on the balls of their feet when sitting on the bike.	Injury Prevention: To ensure the bike is the correct size: When seated, the child should touch the ground with the balls of their feet. When straddling the center bar, feet should be flat on the ground. Improper sizing increases the risk of falls and injury. ⁵⁰
42	A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?	Cuts an outlined shape using scissors	Fine Motor Skills: Using scissors to cut out a shape is an expected milestone for a 4-year-old preschooler. ⁵¹
43	A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?	Absence of peristalsis	Post-Operative Assessment: Immediately following abdominal surgery, especially for a perforation, the bowel is temporarily paralyzed (paralytic ileus). Absence of bowel sounds (peristalsis) is an expected finding until bowel function resumes. ⁵²
44	A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take?	Have the adolescent sign a consent form for treatment	Legal/Ethical Practice: An emancipated minor has the legal status of an adult and can sign consent forms for their own medical treatment, including STI treatment, without parental involvement. ⁵³
45	A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse’s priority?	3 episodes of vomiting⁵⁴⁵⁵	Safety/Toxicity:⁵⁶⁵⁷ While heart failure has many symptoms, vomiting is a hallmark sign of Digoxin toxicity (a common heart failure med). ⁵⁸⁵⁹Using the urgent vs. non-urgent approach, this indicates a potenti⁶⁰al ove⁶¹rdose/toxicity that requires immediate intervention to prevent cardiac arrest. ⁶²
46	A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant’s pain?	Allow the mother to breastfeed while the sample is being obtained	Non-Pharmacological Pain Relief: Evidence-based practice indicates that breastfeeding (or non-nutritive sucking with a pacifier/sucrose) releases endorphins and provides significant pain relief and comfort to infants during painful procedures. ⁶³
47	A nurse is creating a plan of care for a preschooler who has Wilms’ tumor and is scheduled for surgery. Which of the following interventions should the nurse include?	Avoid palpating the abdomen when bathing the child before surgery	Safety Precaution: Wilms’ tumor is an encapsulated kidney tumor. Palpating the abdomen can rupture the capsule, causing cancer cells to disseminate (spread) to adjacent and distant sites. Signs warning “Do Not Palpate Abdomen” are usually placed at the bedside. ⁶⁴
48	A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?	Implement seizure precautions for the infant	Neurological Safety: An epidural hematoma (bleeding between the skull and dura) irritates the brain tissue, placing the infant at high risk for seizure activity. Precautions (padded rails, suction/O2 available) are essential. ⁶⁵
49	A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first?⁶⁶	Explore the parents’ feelings and wishes regarding organ donation⁶⁷	Nursing Process (Assessment):⁶⁸ The first step is always assessment. ⁶⁹The nurse must explore the parents’ emotional state and wishes to determine if ⁷⁰donation is consistent with their values before proceeding with any logistical steps. ⁷¹
50	A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?	Dry, hacking cough	Clinical Manifestations: Pertussis usually begins with mild URI symptoms but progresses to a severe, dry, hacking cough (often worse at night). This cough is the hallmark “whooping cough” presentation. ⁷²
51	A nurse is caring for a preschooler whose guardian is going home for a few hours. Which of the following statements should the nurse make to explain to the child when their guardian will return?	“Your guardian will be back after you eat.”	Cognitive Development: Preschoolers lack a concept of abstract time (hours/minutes). They make sense of time best when it is associated with concrete, expected daily routines like meals, naps, or bedtime. ⁷³
52	A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication?	Erythrocyte sedimentation rate 18 mm/hr	Infection Indicators: The expected ESR for a child is up to 10 mm/hr. An elevated ESR (18 mm/hr) indicates inflammation. In a post-op fracture patient, this is a strong indicator of osteomyelitis (bone infection), a serious complication. ⁷⁴
53	Case Study (Sickle Cell): The nurse should first address the child’s ______, followed by the child’s ______.	First: Oxygen Saturation Followed by: Pain	Prioritization: 1. Oxygen: The child’s saturation is below range (Hypoxia). Hypoxia causes the red blood cells to sickle, obstructing blood flow. Correcting hypoxia stops the sickling process (physiological safety). 2. Pain: The pain is severe (8/10), but it is a symptom of the ischemia caused by sickling. You must treat the cause (hypoxia) first, then manage the pain. ⁷⁵
54	Case Study (Appendectomy): Select the 3 findings that the nurse should identify as indications of a potential complication.	1. WBC count (High) 2. Abdomen assessment (Rigid/Distended) 3. Temperature (High)	Post-Op Infection/Peritonitis: * WBC: Increased significantly (12,000+), indicating infection.⁷⁶ * Abdomen: Rigid/distended abdomen suggests peritonitis (inflammation of the abdominal lining).⁷⁷ * Temp: Fever indicates systemic infection. ⁷⁸⁷⁹
55⁸⁰	A community health⁸¹ nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect?	Poor personal hygiene	Signs of Neglect: Toddlers are dependent on caregivers for hygiene. Consistent poor personal hygiene (dirty clothes, unwashed body, severe diaper rash) indicates a lack of supervision and failure to meet the child’s basic needs. ⁸²⁸³
56⁸⁴	Case Study (Renal): For each EMR fi⁸⁵nding, specify if it is consistent with Nephrotic Syndrome, Acute Poststreptococcal Glomerulonephritis, or Hemolytic Uremic Syndrome (HUS).	Temperature: Glomerulonephritis & HUS BUN Level: Glomerulonephritis & HUS Platelet Count: HUS	Differentiation:⁸⁶⁸⁷ * Glomerulonephritis: Follows strep infection; causes fever and renal impairment (High BUN).⁸⁸⁸⁹ * HUS: Causes fever (sometimes hallucinations), renal failure (High BUN), and specifically thrombocytopenia ⁹⁰(low platelets⁹¹) due to intravascular coagulation. ⁹²
57	Case Study (Hemophilia): For each potential provider’s prescription, click to specify if it is Anticipated or Contraindicated.	1. Administer factor VIII: Anticipated 2. Apply ice packs: Anticipated 3. Administer morphine: Anticipated	Hemophilia Management: * Factor VIII: Replaces the missing clotting factor to control bleeding. * Ice Packs: Vasoconstriction helps stop bleeding and reduces swelling in the joint (hemarthrosis). * Morphine: Severe joint bleeding is incredibly painful; opioids are appropriate. (Note: Aspirin/NSAIDs are contraindicated as they inhibit platelets). ⁹³
58	Case Study (Croup/LTB): Upon evaluation of the infant’s status at 0630, the nurse should identify which of the following as signs of improvement?	1. Infant is sleeping in parent’s arms 2. SpO2 is 96% with cool mist 3. Breath sounds present/equal 4. Infant voided 34 mL	Evaluation of Care: * Sleeping: Indicates restlessness (a sign of hypoxia) has resolved. * SpO2: Improved from 89% to 96% (Hypoxia resolved). * Breath Sounds: Better air entry indicates reduced airway swelling.⁹⁴⁹⁵ * Voiding: Indicates hydration is improving (previously had not voided in 12hr). ⁹⁶⁹⁷⁹⁸
59⁹⁹¹⁰⁰	A nurse is caring for a 15-year-old cli¹⁰¹ent following a head injury. Which of the following findi¹⁰²ngs should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?	Mental confusion	Pathophysiology of SIADH: Head injury can cause over-secretion of ADH. This causes the body to retain too much water, diluting the blood (hemodilution). This results in hyponatremia (low sodium). Severe hyponatremia causes cerebral edema (brain swelling), leading to mental confusion and seizures. ¹⁰³
60	A nurse is providing discharge teaching to the parents of a 3-month-old infant following a cheiloplasty. Which of the following instructions should the nurse include?	“Apply a thin layer of antibiotic ointment on your baby’s suture line daily for the next 3 days.”	Post-Op Wound Care: Cheiloplasty is a cleft lip repair. To promote healing and prevent infection, the suture line must be kept clean and lubricated. Antibiotic ointment is used initially, followed by petroleum jelly. ¹⁰⁴

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RN Pediatric Nursing Online Practice 2023 A – Comprehensive Study Guide

Question 1: Emergency Management of Anaphylactic Reaction

Question: A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

Answer: Administer epinephrine intramuscularly (IM)

Detailed Rationale: When utilizing the urgent versus non-urgent approach to client care in pediatric emergencies, the nurse must recognize that administering epinephrine IM is the absolute priority intervention for anaphylactic reactions. During anaphylaxis, massive histamine release causes severe bronchoconstriction and widespread vasodilation, leading to:

Airway obstruction from bronchospasm and laryngeal edema
Cardiovascular collapse from vasodilation and increased capillary permeability
Decreased venous return to the heart
Potential for rapid progression to cardiac arrest

Epinephrine works by:

Reversing bronchospasm through beta-2 adrenergic stimulation
Causing vasoconstriction through alpha-adrenergic effects
Stabilizing mast cells to prevent further histamine release
Improving cardiac contractility through beta-1 stimulation

The intramuscular route (preferably in the anterolateral thigh) provides rapid absorption and is the recommended route for emergency treatment. Delay in epinephrine administration is associated with increased mortality in anaphylaxis.

Question 2: Pneumothorax Management in Adolescents

Question: A nurse in a pediatric emergency department is planning care for an adolescent. Based on the information in the adolescent’s medical record, which of the following actions should the nurse plan to take? Select all that apply.

Answer:

Apply supplemental oxygen
Prepare for chest tube insertion

Detailed Rationale:

Apply Supplemental Oxygen: According to the medical record and chest x-ray findings indicating potential pneumothorax, the adolescent’s oxygen saturation levels are decreasing, indicating hypoxia. Supplemental oxygen is essential to:

Maintain adequate tissue oxygenation
Compensate for decreased lung expansion
Support respiratory function while definitive treatment is initiated
Potentially accelerate reabsorption of pneumothorax through nitrogen washout

Prepare for Chest Tube Insertion: A pneumothorax represents air accumulation in the pleural space, causing lung collapse and respiratory compromise. The adolescent may experience:

Dyspnea and tachypnea
Tachycardia
Progressive hypoxia
Pleuritic chest pain
Potential for tension pneumothorax development

Chest tube insertion (thoracostomy) is indicated to:

Remove air from the pleural cavity
Re-establish negative pressure
Allow lung re-expansion
Prevent cardiovascular compromise
Monitor for ongoing air leak

The nurse should prepare sterile equipment, positioning supplies, and ensure appropriate sedation/analgesia orders are available.

Question 3: Epiglottitis Emergency Care

Question: A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take?

Answer: Monitor the child’s oxygen saturation continuously

Detailed Rationale: Continuous oxygen saturation monitoring is critical for a child with epiglottitis because:

Pathophysiology Considerations:

Epiglottitis causes rapid inflammation and edema of the epiglottis and supraglottic structures
Can progress to complete airway obstruction within hours
The child is experiencing acute respiratory distress requiring constant assessment

Monitoring Rationale:

Oxygen saturation provides real-time assessment of respiratory status
Early detection of deterioration allows for timely intervention
Helps evaluate response to treatment (antibiotics, steroids)
Guides need for emergency airway management

Additional Nursing Considerations:

Keep child calm and in position of comfort (usually sitting upright, leaning forward)
Avoid throat examination or procedures that could precipitate complete obstruction
Have emergency intubation equipment immediately available
Prepare for possible emergency tracheostomy if intubation fails
Administer humidified oxygen as tolerated
Monitor for signs of impending obstruction (stridor, retractions, cyanosis)

Question 4: Preschooler Play Activities for Development

Question: A nurse is providing teaching about play activities for social development to the guardians of a preschooler. Which of the following play activities should the nurse recommend for the child?

Answer: Playing dress-up

Detailed Rationale: Playing dress-up is an ideal activity for preschool-age children (ages 3-5 years) because it supports multiple developmental domains:

Social Development:

Encourages role-playing and understanding different social roles
Promotes sharing and turn-taking when playing with others
Develops empathy through pretending to be different characters
Facilitates cooperative play with peers

Cognitive Development:

Stimulates imagination and creative thinking
Develops symbolic thinking and representation
Enhances problem-solving skills
Supports language development through storytelling

Emotional Development:

Allows expression of feelings through play
Helps process experiences and emotions
Builds self-confidence
Provides safe exploration of different identities

Physical Development:

Fine motor skills through manipulating clothing fasteners
Gross motor coordination while changing clothes
Body awareness and self-care skills

The nurse should emphasize that preschoolers learn best through play that integrates social interaction, mental stimulation, and physical activity.

Question 5: Prioritizing Care for Multiple Patients

Question: A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first?

Answer: A school-age child who has sickle cell anemia and reports decreased vision in the left eye

Detailed Rationale: Using the urgent versus non-urgent approach to client prioritization, the nurse must recognize that decreased vision in a child with sickle cell disease represents a medical emergency:

Pathophysiology of Ocular Crisis:

Vaso-occlusive crisis can affect retinal vessels
Sickled cells obstruct blood flow to the retina
Can cause retinal detachment or proliferative retinopathy
Risk of permanent vision loss without immediate treatment

Why This is the Priority:

Represents acute vaso-occlusive crisis requiring immediate intervention
Time-sensitive condition where delays can result in permanent disability
Requires immediate provider notification
May need emergency treatment including:
- Exchange transfusion
- High-dose oxygen therapy
- IV hydration
- Pain management
- Possible ophthalmologic intervention

Complications to Prevent:

Permanent vision loss
Retinal hemorrhage
Vitreous hemorrhage
Retinal detachment
Complete blindness

The nurse should immediately assess visual acuity, notify the provider, and prepare for emergency interventions.

Question 6: Digoxin Administration Teaching

Question: A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching?

Answer: “Brush the child’s teeth after giving the medication.”

Detailed Rationale: This instruction is crucial for pediatric digoxin administration:

Medication Formulation:

Pediatric digoxin comes as a sweetened liquid elixir
The high sugar content is added to enhance palatability
Makes the medication more acceptable to young children

Dental Health Concerns:

Frequent exposure to sweetened medications increases cavity risk
Preschoolers are particularly vulnerable to dental caries
Sugar residue can adhere to teeth and promote bacterial growth
Twice-daily administration means repeated sugar exposure

Additional Digoxin Teaching Points:

Check apical pulse for full minute before administration
Hold if heart rate below age-appropriate parameters
Use accurate measuring device (not household spoon)
Give at consistent times daily
Never double doses if one is missed
Watch for signs of toxicity (nausea, vomiting, vision changes)
Keep medication out of reach of children
Regular blood level monitoring required

Oral Hygiene Protocol:

Brush teeth immediately after medication
If brushing not possible, rinse mouth with water
Consider fluoride supplements if recommended
Regular dental check-ups important

Question 7: Diaper Dermatitis Treatment

Question: A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area?

Answer: Zinc oxide

Detailed Rationale: Zinc oxide is the gold standard treatment for diaper dermatitis:

Mechanism of Action:

Creates a physical barrier protecting skin from irritants
Prevents contact with urine, feces, and moisture
Has mild antiseptic and astringent properties
Promotes healing of damaged skin
Reduces friction between diaper and skin

Pathophysiology of Diaper Dermatitis:

Common inflammatory skin disorder in infants
Caused by prolonged contact with irritants (urine, feces, soap)
Friction from diaper movement exacerbates condition
Presents as erythema, scaling, blisters, or papules
Can progress to secondary infection if untreated

Application Instructions:

Clean area gently with warm water
Pat dry completely (don’t rub)
Apply thick layer of zinc oxide with each diaper change
No need to remove all previous application
Continue until rash resolves

Additional Management Strategies:

Frequent diaper changes (every 2-3 hours)
Use super-absorbent disposable diapers
Allow diaper-free time for air exposure
Avoid harsh wipes containing alcohol or fragrance
Consider probiotic use if antibiotic-related
Seek medical attention if no improvement in 3 days

Question 8: IV Discontinuation Procedure

Question: A nurse is caring for a client who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Answer: Correct sequence:

Turn off the IV pump
Occlude the IV tubing
Remove the tape securing the catheter
Apply pressure over the catheter insertion site

Detailed Rationale:

Step 1 – Turn off the IV pump:

Prevents continued fluid infusion during removal
Eliminates pressure in the line
Ensures accurate intake documentation
Prevents fluid spillage

Step 2 – Occlude the IV tubing:

Prevents backflow of blood
Minimizes bleeding risk
Prevents air entry into catheter
Maintains closed system until removal

Step 3 – Remove tape securing the catheter:

Gentle removal prevents skin trauma
Remove in direction of hair growth
Use adhesive remover if needed for sensitive skin
Stabilize catheter during tape removal

Step 4 – Apply pressure over the catheter insertion site:

Apply immediately after catheter removal
Maintain pressure for 2-3 minutes minimum
Longer if patient on anticoagulants
Promotes hemostasis and prevents hematoma
Apply sterile dressing after bleeding stops

Documentation Requirements:

Time of discontinuation
Catheter condition and length
Site appearance
Patient tolerance
Any complications

Question 9: Biceps Reflex Assessment

Question: A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex.

Answer: The antecubital fossa area (inner elbow)

Detailed Rationale: The biceps reflex assessment is crucial in evaluating spinal cord function:

Anatomical Location:

Tap the biceps tendon in the antecubital fossa
Located at the bend of the elbow
Tendon lies over the radius bone
C5-C6 nerve root levels tested

Assessment Technique:

Position arm at 45-degree angle
Support the elbow with examiner’s hand
Place thumb over biceps tendon
Strike thumb with reflex hammer
Observe for elbow flexion

Clinical Significance in Spinal Cord Injury:

Tests integrity of C5-C6 reflex arc
Hyperreflexia indicates upper motor neuron damage
Absent reflex suggests lower motor neuron involvement
Helps localize level of spinal cord injury
Monitors recovery progress

Expected Findings:

Normal: 2+ (brisk response)
Hyperreflexia: 3+ to 4+ (may indicate spinal cord compression above C5-C6)
Hyporeflexia: 0 to 1+ (may indicate injury at C5-C6 level)

Additional Assessment:

Compare bilateral responses
Assess other deep tendon reflexes
Evaluate motor strength
Check sensation levels

Question 10: Immunocompromised Child Care

Question: A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?

Answer: Screen the child’s visitors for indications of infection

Detailed Rationale: Protecting severely immunocompromised children from infection is paramount:

Immunocompromised State:

Chemotherapy destroys rapidly dividing cells including WBCs
Neutropenia (ANC <500) creates severe infection risk
Unable to mount adequate immune response
Minor infections can become life-threatening
Risk of opportunistic infections

Visitor Screening Protocol:

Assess for signs/symptoms of infection:
- Fever or feeling unwell
- Cough, runny nose, sore throat
- Rash or skin infections
- Gastrointestinal symptoms
- Recent exposure to communicable diseases
Restrict visitors with active infections
Limit number of visitors
Ensure proper hand hygiene
Provide masks if indicated

Additional Protective Measures:

Private room placement
Neutropenic precautions
No fresh flowers or plants
Cooked food only (no raw fruits/vegetables)
Daily assessment for infection signs
Prompt antibiotic therapy for fever
Avoid invasive procedures when possible
Meticulous central line care

Education Points:

Importance of infection prevention
Signs requiring immediate medical attention
Home environment preparation
Avoiding crowds and sick contacts

Question 11: Oral Nystatin Administration

Question: A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?

Answer: “Shake the medication prior to administration.”

Detailed Rationale: Proper administration of nystatin suspension is essential for effectiveness:

Medication Preparation:

Nystatin oral suspension requires thorough shaking
Medication particles settle when stored
Shaking ensures uniform drug distribution
Provides consistent dosing
Maximizes therapeutic effect

Administration Technique:

Shake bottle vigorously for 10 seconds
Use calibrated measuring device
Have child swish medication in mouth
Hold in mouth as long as possible (ideally 2 minutes)
Swallow after swishing
Avoid eating/drinking for 30 minutes after

Mechanism of Action:

Direct contact with fungal organisms required
Binds to fungal cell membrane
Creates pores causing cell death
Limited systemic absorption
Local action in oral cavity

Treatment Considerations:

Continue full course even if symptoms improve
Usually prescribed QID (four times daily)
Treatment duration typically 7-14 days
May cause temporary taste alteration
Watch for signs of treatment failure

Storage Instructions:

Store at room temperature
Keep bottle tightly closed
Protect from light
Check expiration date
Discard after treatment course

Question 12: Infectious Mononucleosis Education

Question: A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding of the teaching?

Answer: “Mononucleosis is caused by an infection with the Epstein-Barr virus.”

Detailed Rationale: Understanding the etiology of mononucleosis is important for parent education:

Causative Agent:

Epstein-Barr virus (EBV) causes 90% of cases
Member of herpesvirus family
Other causes include CMV, toxoplasmosis
Virus remains dormant after initial infection

Transmission:

Spread through saliva (“kissing disease”)
Sharing drinks, utensils, toothbrushes
Not highly contagious despite reputation
Incubation period 4-6 weeks

Clinical Presentation:

Classic triad: fever, pharyngitis, lymphadenopathy
Extreme fatigue lasting weeks to months
Splenomegaly in 50% of cases
Hepatomegaly possible
Characteristic atypical lymphocytes on CBC

Management:

Supportive care (rest, fluids, antipyretics)
Avoid contact sports due to splenic rupture risk
No antibiotics unless secondary infection
Avoid amoxicillin (causes characteristic rash)
Corticosteroids for severe complications only

Complications to Monitor:

Splenic rupture
Airway obstruction
Hepatitis
Thrombocytopenia
Neurologic complications

Return to Activities:

Gradual return as tolerated
No contact sports for minimum 3 weeks
May need modified school schedule
Full recovery typically 2-3 months

Question 13: Heart Failure Nutritional Management

Question: A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?

Answer: Provide small, frequent meals for the child

Detailed Rationale: Nutritional management is crucial in pediatric heart failure:

Metabolic Demands:

Increased metabolic rate due to poor cardiac function
Higher caloric needs (120-150% of normal)
Increased work of breathing burns calories
Poor growth common in heart failure

Benefits of Small, Frequent Meals:

Reduces energy expenditure during feeding
Prevents stomach distension affecting breathing
Decreases cardiac workload
Improves overall caloric intake
Reduces nausea and early satiety

Feeding Strategies:

Offer 5-6 small meals daily
High-calorie, nutrient-dense foods
Limit fluids during meals
Position upright for feeding
Allow rest periods during meals
Consider caloric supplements

Additional Interventions:

Daily weights to monitor fluid status
Sodium restriction as ordered
Monitor intake and output
Assess for signs of fatigue during feeding
Consider nasogastric feeds if oral intake inadequate

Signs of Feeding Intolerance:

Tachypnea during feeding
Diaphoresis
Cyanosis
Poor weight gain
Prolonged feeding times (>30 minutes)

Question 14: Toddler Behavioral Development

Question: A nurse is providing anticipatory guidance to the guardian of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?

Answer: Expresses likes and dislikes

Detailed Rationale: Understanding toddler development helps guardians manage challenging behaviors:

Developmental Milestone:

Expressing preferences is normal for toddlers (1-3 years)
Demonstrates developing autonomy
Key feature of Erikson’s “Autonomy vs. Shame and Doubt” stage
Essential for self-concept formation

Autonomy Development:

Toddlers assert independence through choices
“No” becomes favorite word
Tests boundaries and limits
Develops sense of self as separate individual

Behavioral Manifestations:

Strong food preferences
Clothing choices (wanting to dress self)
Toy preferences
Routine preferences
Selective about caregivers

Guidance for Parents:

Offer limited choices (2-3 options)
Set consistent, reasonable limits
Avoid power struggles
Redirect negative behavior
Praise positive choices
Maintain routines for security

Managing Challenging Behaviors:

Tantrums are normal when frustrated
Use distraction techniques
Stay calm during outbursts
Time-outs for 1-2 minutes per year of age
Consistent consequences

Safety Considerations:

Childproof environment for exploration
Supervise constantly
Teach “no” for dangerous situations
Balance freedom with safety

Question 15: Room Assignment Priorities

Question: A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse’s priority?

Answer: Disease process

Detailed Rationale: Infection control and disease transmission prevention are paramount in room assignments:

Priority Rationale:

Disease process determines isolation requirements
Prevents cross-contamination between patients
Protects immunocompromised patients
Ensures appropriate precautions implemented

Infection Control Considerations:

Airborne precautions need negative pressure rooms
Droplet/contact precautions may need private rooms
Immunocompromised patients need protective environment
Cohort patients with same organisms when necessary

Room Assignment Factors:

Disease Process (Priority):
- Infectious vs. non-infectious
- Type of organism
- Transmission route
- Isolation requirements
Secondary Considerations:
- Age and developmental needs
- Gender (for older children)
- Acuity level
- Family preferences
- Special equipment needs

Examples of Room Assignments:

RSV patients can room together
Varicella requires airborne isolation
MRSA needs contact precautions
Chemotherapy patients need protective isolation
Post-operative patients away from infections

Documentation:

Reason for room selection
Precautions initiated
Family education provided
Any special accommodations

Question 16: Burn Wound Hydrotherapy

Question: A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?

Answer: Administer an analgesic to the child

Detailed Rationale: Pain management is critical before burn wound hydrotherapy:

Procedure Pain Level:

Hydrotherapy is extremely painful
Water pressure and debridement cause severe pain
Nerve endings exposed in partial-thickness burns
Movement and manipulation increase discomfort

Premedication Timing:

Administer analgesics 30-60 minutes before
Allows peak effect during procedure
Consider both opioid and non-opioid options
May require sedation for young children

Pain Management Benefits:

Reduces physiological stress response
Decreases risk of shock
Improves cooperation during procedure
Prevents psychological trauma
Reduces risk of PTSD development

Medication Options:

Morphine or fentanyl IV
Oral opioids for less severe burns
Anxiolytics (midazolam) for anxiety
Consider ketamine for procedural sedation
Topical anesthetics where appropriate

Additional Comfort Measures:

Explain procedure age-appropriately
Allow parent presence if possible
Use distraction techniques
Maintain warm environment
Gentle handling
Stop periodically if tolerated

Post-Procedure Care:

Continue pain assessment
Provide comfort positioning
Monitor for signs of distress
Document pain scores
Adjust ongoing pain management

Question 17: Asthma Trigger Prevention

Question: A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?

Answer: “I should keep my child indoors when I mow the yard.”

Detailed Rationale: Environmental control is essential in asthma management:

Outdoor Allergen Exposure:

Grass clippings are major asthma triggers
Lawn mowing releases grass pollen
Creates airborne particles
Mold spores from cut grass
Chemical emissions from mower

Common Outdoor Triggers:

Tree, grass, and weed pollens
High pollen count days
Air pollution/ozone
Temperature extremes
High humidity
Strong winds carrying allergens

Prevention Strategies:

Monitor daily pollen counts
Keep windows closed during high pollen days
Use air conditioning with HEPA filters
Shower and change clothes after outdoor play
Avoid outdoor activities during peak pollen hours (early morning)
Pre-medicate before unavoidable exposure

Indoor Trigger Control:

Dust mite covers on bedding
Remove carpeting if possible
Control humidity (<50%)
No pets in bedroom
Avoid smoking in home
Regular HVAC filter changes
Minimize stuffed animals

Action Plan Education:

Green zone: Good control
Yellow zone: Caution, use quick-relief medication
Red zone: Medical emergency
When to call provider
Proper inhaler technique

Question 18: Iron Deficiency Anemia Nutrition

Question: A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron?

Answer: ½ cup raisins

Detailed Rationale: Understanding iron sources helps manage nutritional anemia:

Iron Content Comparison:

Raisins: Highest nonheme iron among common foods
½ cup provides approximately 1.5-2mg iron
Concentrated source due to dehydration
Also provides energy for anemic patients

Types of Dietary Iron:

Heme Iron (15-35% absorption):
- Found in animal products
- Red meat, poultry, fish
- Better absorbed than nonheme
Nonheme Iron (2-20% absorption):
- Plant sources
- Fortified cereals
- Beans and lentils
- Dark leafy greens
- Dried fruits

Absorption Enhancement:

Vitamin C increases nonheme absorption
Combine with citrus fruits
Avoid tea/coffee with meals (tannins inhibit)
Cast iron cookware adds iron
Separate calcium supplements from iron-rich meals

Adolescent Iron Needs:

Boys: 11mg/day
Girls: 15mg/day (higher due to menses)
Athletes need more
Vegetarians need 1.8x more

Additional Dietary Sources:

Fortified breakfast cereals
Spinach and dark greens
Beans and lentils
Quinoa
Dark chocolate
Pumpkin seeds

Question 19: Juvenile Idiopathic Arthritis Care

Question: A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching?

Answer: “Encourage the child to perform independent self-care.”

Detailed Rationale: Promoting independence is crucial in managing juvenile idiopathic arthritis:

Benefits of Independent Self-Care:

Maintains joint mobility and function
Prevents muscle atrophy
Preserves range of motion
Builds self-esteem and confidence
Promotes normal development
Reduces learned helplessness

Pain and Mobility Balance:

Movement may cause initial discomfort
Gentle activity reduces stiffness
“Motion is lotion” for joints
Inactivity worsens symptoms
Finding balance is key

Age-Appropriate Self-Care:

Dressing with adaptive equipment
Modified grooming tools
Velcro instead of buttons
Lever-style door handles
Built-up handles on utensils

Exercise Program:

Daily range-of-motion exercises
Swimming for low-impact activity
Physical therapy involvement
Avoid high-impact sports during flares
Warm-up importance

Family Teaching Points:

Praise efforts, not just success
Allow extra time for tasks
Provide assistance only when needed
Encourage participation in school
Maintain normal expectations when possible

Medication Compliance:

Importance of anti-inflammatory medications
Disease-modifying drugs (DMARDs)
Biologic agents if indicated
Regular monitoring required

Question 20: Lumbar Puncture Preparation

Question: A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?

Answer: Apply topical analgesic cream to the site 1 hour prior to the procedure

Detailed Rationale: Proper preparation minimizes discomfort during lumbar puncture:

Topical Anesthetic Application:

EMLA or LMX cream commonly used
Apply 60 minutes before procedure
Covers 2-3 interspaces (usually L3-L4, L4-L5)
Cover with occlusive dressing
Penetrates 3-5mm depth

Benefits of Topical Anesthesia:

Reduces needle insertion pain
Decreases anxiety
Improves cooperation
Allows better positioning
Reduces need for restraint

Positioning for Procedure:

Side-lying fetal position most common
Knees to chest, chin tucked
Or sitting position leaning forward
Maintain airway alignment
Assistant helps maintain position

Adolescent-Specific Considerations:

Explain procedure honestly
Address specific fears
Allow questions
Respect modesty/privacy
Consider parent presence preference
Offer coping strategies

Pre-Procedure Preparation:

NPO status usually not required
Empty bladder for comfort
Baseline vital signs
Remove jewelry from area
Consent verification

During Procedure Support:

Coaching breathing techniques
Distraction methods
Continuous monitoring
Reassurance and praise
Monitor for vagal response

Question 21-26: Lead Poisoning Case Study

Question 21: Recognizing Lead Poisoning Risk Factors

Question: A nurse in the outpatient pediatric clinic is caring for a 2-year-old child. Click to highlight the findings that require follow-up.

Findings Requiring Follow-up:

Pale pink mucous membranes
Living in an older urban house being renovated
Parent reports toddler seems less active and gets tired more quickly

Detailed Rationale: These findings create a constellation of lead poisoning risk factors and symptoms:

Environmental Risk – Older Urban House Under Renovation:

Houses built before 1978 likely contain lead paint
Renovation disturbs lead paint creating dust/chips
Aerosolized lead particles during sanding/scraping
Toddlers at high risk due to hand-to-mouth behavior
Crawling on contaminated floors
Lead dust on toys and surfaces

Clinical Manifestations – Pale Mucous Membranes:

Lead interferes with heme synthesis
Causes microcytic, hypochromic anemia
Results in pallor and fatigue
May see basophilic stippling on blood smear

Behavioral Changes – Decreased Activity/Fatigue:

Early signs of lead toxicity
Related to anemia
May progress to irritability
Developmental regression possible
Cognitive impacts if untreated

Question 22: Lead Poisoning Complications

Question: Drag words from the choices below to fill in each blank in the following sentence regarding the child at risk for lead poisoning.

Answer: The child is at risk for developing intellectual deficits due to the increase in membrane permeability of the brain tissue resulting in increased intracranial pressure, tissue ischemia, and atrophy. The nurse should also identify that the child is at risk for decreased kidney function due to the damage of the proximal tubules caused by the elevated blood lead level.

Detailed Rationale:

Neurological Complications:

Lead crosses blood-brain barrier easily
Increases membrane permeability
Causes cerebral edema and increased ICP
Results in tissue ischemia and atrophy
Permanent cognitive deficits possible:
- Decreased IQ (loses 2-3 points per 10 mcg/dL increase)
- Learning disabilities
- Behavioral problems
- ADHD symptoms
- Speech delays

Renal Complications:

Lead damages proximal tubules
Causes Fanconi syndrome
Results in:
- Glycosuria
- Proteinuria
- Ketonuria
- Phosphate wasting
Can progress to chronic kidney disease
Usually reversible if treated early

Question 23: Prioritizing Lead Poisoning Interventions

Question: Complete the following sentence by using the lists of options. The nurse should first address the child’s __________, followed by the child’s __________.

Answer: The nurse should first address the child’s elevated BLL (blood lead level), followed by the child’s hemoglobin.

Detailed Rationale:

Priority – Elevated Blood Lead Level:

Source of all complications
Must stop ongoing exposure
Initiate chelation if indicated
Environmental investigation needed
Time-sensitive to prevent permanent damage

Secondary Priority – Hemoglobin:

Anemia is consequence of lead toxicity
Will improve with lead treatment
Iron supplementation may be needed
Monitor response to treatment

Rationale for Prioritization:

Lead is the causative agent
Removing lead allows heme synthesis recovery
Anemia will not resolve without addressing lead
Cognitive effects worsen with continued exposure
Early intervention prevents permanent damage

Question 24: Anticipated Interventions for Lead Poisoning

Question: For each potential provider prescription, click to specify if the prescription is anticipated or contraindicated for the client with lead poisoning.

Anticipated Prescriptions:

Succimer (chelation therapy)
Ferrous sulfate (iron supplementation)
Dietitian consult
Social Services consult

Detailed Rationale:

Succimer (DMSA) – Anticipated:

Chelating agent for BLL >45 mcg/dL
Binds lead for urinary excretion
Oral administration (outpatient option)
Given for 19-day course
Requires adequate hydration
Monitor renal function

Ferrous Sulfate – Anticipated:

Treats concurrent iron deficiency anemia
Given between chelation rounds
Not during active chelation (competes for binding)
Enhances erythropoiesis
Monitor for constipation

Dietitian Consult – Anticipated:

High calcium diet (competes with lead absorption)
High iron foods
Low fat diet (fat increases lead absorption)
Vitamin C to enhance iron absorption
Adequate nutrition for growth

Social Services Consult – Anticipated:

Housing assessment and remediation
Temporary housing during renovation
Financial assistance resources
Lead-safe housing identification
Family support services
Follow-up coordination

Question 25: Discharge Teaching for Lead Poisoning

Question: The nurse is providing discharge teaching to the parent. Which of the following information should the nurse include? Select all that apply.

Answer: All of the following should be included:

Open succimer capsule and sprinkle on 1 teaspoon of applesauce
Use wet cloth for dusting
Give ferrous sulfate with straw
Offer orange juice with iron medication
Monitor wet diapers
Prevent playing in soil near house

Detailed Rationale:

Medication Administration:

Succimer on applesauce: 2-year-olds cannot swallow capsules; mixing with small amount ensures full dose consumed
Ferrous sulfate with straw: Prevents teeth staining from liquid iron
Orange juice with iron: Vitamin C enhances iron absorption significantly

Environmental Controls:

Wet dusting: Prevents lead dust from becoming airborne; dry dusting spreads contamination
Avoid soil near house: Likely contaminated with lead from paint chips and dust

Monitoring:

Wet diapers: Ensures adequate hydration during chelation; prevents renal toxicity from succimer

Question 26: Evaluating Lead Poisoning Treatment Outcomes

Question: Which of the following conditions are improving since the child’s visit 1 month ago? Select 4.

Answer:

Lead poisoning (decreased BLL)
Kidney function (decreased glycosuria)
Exposure to lead (moved from house)
Nutritional status (weight gain, eating calcium-rich foods)

Detailed Rationale:

Lead Poisoning Improvement:

BLL decreased from initial elevated level
Indicates chelation therapy effective
Reduced body burden of lead
Continued monitoring needed

Kidney Function Improvement:

Decreased glucose in urine
Proximal tubule function recovering
Reversible damage with treatment
May need continued monitoring

Environmental Exposure Reduced:

Family moved from contaminated house
Primary source of exposure removed
Critical for preventing reexposure
Allows treatment to be effective

Nutritional Status Improved:

Weight gain indicates better intake
Calcium-rich diet implemented
Competing with lead absorption
Supporting overall growth and development

Question 27: Recognizing Anemia in Children

Question: A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?

Answer: Hematocrit 28%

Detailed Rationale: Understanding normal pediatric lab values is essential:

Normal Hematocrit Ranges:

School-age children (6-12 years): 32-44%
Patient’s result: 28% (significantly below normal)
Indicates decreased RBC mass
Confirms anemia diagnosis

Clinical Correlation with Fatigue:

Decreased oxygen-carrying capacity
Tissue hypoxia
Compensatory mechanisms:
- Tachycardia
- Tachypnea
- Fatigue/weakness

Additional Manifestations:

Pallor (skin, conjunctiva, nail beds)
Lightheadedness/dizziness
Decreased exercise tolerance
Poor concentration
Headaches
Cold intolerance

Diagnostic Workup:

Complete blood count with differential
Reticulocyte count
Iron studies
B12/folate levels
Hemoglobin electrophoresis if indicated

Common Causes in School-Age Children:

Iron deficiency (most common)
Chronic disease
Blood loss
Hemolytic disorders
Nutritional deficiencies

Question 28: Immunization Contraindications

Question: A nurse in a provider’s office is preparing to administer immunizations to a toddler during a well-child visit. The child has a history of anaphylaxis to neomycin. Which of the following actions should the nurse plan to take?

Answer: Withhold the measles, mumps, and rubella (MMR) vaccine

Detailed Rationale: Recognizing vaccine contraindications prevents severe adverse reactions:

MMR Vaccine Components:

Contains trace amounts of neomycin
Used as preservative/stabilizer
Present in final vaccine product

Anaphylaxis to Neomycin:

Absolute contraindication to MMR
Life-threatening allergic reaction risk
IgE-mediated hypersensitivity
Previous anaphylaxis predicts future risk

Other Vaccines Containing Neomycin:

Varicella vaccine
Some IPV formulations
Some influenza vaccines
Always check package inserts

Alternative Management:

Document allergy clearly
Consult with allergist/immunologist
Consider component vaccines if available
Ensure herd immunity through family vaccination
Medical exemption documentation

Other MMR Contraindications:

Severe egg allergy (manufactured in chick embryo)
Gelatin allergy
Immunodeficiency
Pregnancy
Recent blood product receipt

Safe to Administer:

DTaP vaccine (no neomycin)
Hepatitis B vaccine
Pneumococcal vaccine
Rotavirus vaccine

Question 29: Shock Management Priority

Question: A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child’s respirations, which of the following actions should the nurse take next?

Answer: Initiate IV access

Detailed Rationale: Following the ABC (Airway, Breathing, Circulation) approach:

Circulation Priority After Airway/Breathing:

IV access essential for circulatory support
Enables fluid resuscitation
Allows medication administration
Restores intravascular volume
Maintains organ perfusion

Pediatric Shock Considerations:

Children compensate longer than adults
Hypotension is late sign
Early intervention crucial
Rapid decompensation possible

IV Access Strategies:

Two large-bore IVs preferred
Antecubital sites ideal
Intraosseous if IV fails (after 2 attempts or 90 seconds)
Central line for vasopressors

Fluid Resuscitation:

Initial bolus: 20 mL/kg isotonic crystalloid
Reassess after each bolus
May need 60-80 mL/kg in first hour
Monitor for fluid overload
Consider blood products if hemorrhagic

Concurrent Actions:

Continuous monitoring
Frequent vital signs
Urine output monitoring
Laboratory studies
Identify underlying cause

Question 30: Kidney Transplant Rejection

Question: A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?

Answer: Serum creatinine 3.0 mg/dL

Detailed Rationale: Monitoring for transplant rejection requires understanding of renal function markers:

Creatinine Significance:

Normal adolescent range: 0.4-1.0 mg/dL
Patient’s level: 3.0 mg/dL (significantly elevated)
Indicates decreased kidney filtration
Byproduct of muscle metabolism
Not reabsorbed or secreted significantly

Acute Rejection Signs:

Rising creatinine (earliest indicator)
Decreased urine output
Fluid retention/edema
Hypertension
Graft tenderness
Fever
Malaise

Types of Rejection:

Hyperacute: Minutes to hours (rare with crossmatching)
Acute: Days to months (most common)
Chronic: Months to years (progressive)

Additional Monitoring:

BUN elevation
Proteinuria
Electrolyte imbalances
Decreased GFR
Biopsy for definitive diagnosis

Management:

High-dose corticosteroids
Adjustment of immunosuppressants
Anti-rejection antibodies
Plasmapheresis if severe
Close monitoring

Question 31: Lead Screening Guidelines

Question: A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?

Answer: Schedule the toddler for a yearly re-screening

Detailed Rationale: Current CDC lead screening guidelines:

Lead Level Interpretation:

<3.5 mcg/dL: No elevated blood lead level
3.5-5 mcg/dL: Review in 6-12 months
Patient’s level: 4 mcg/dL (mild elevation)

Yearly Screening Rationale:

Level not immediately dangerous
Monitor for increase
Risk factors may persist
Developmental vulnerability continues
Early detection prevents toxicity

Education Focus:

Nutrition optimization
Environmental assessment
Hand hygiene
Cleaning practices
Water testing
Toy safety

Risk Factor Assessment:

Housing age and condition
Renovation/remodeling
Parent occupations
Cultural practices
Imported items
Previous elevated levels

When to Increase Frequency:

Level rises above 5 mcg/dL
High-risk environment
Symptoms develop
Sibling with elevated level
Ongoing exposure suspected

Question 32: McBurney’s Point Assessment

Question: A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney’s point?

Answer: The point located in the right lower quadrant, approximately two-thirds of the distance from the umbilicus to the anterior superior iliac spine

Detailed Rationale: McBurney’s point is a crucial landmark for appendicitis assessment:

Anatomical Location:

Right lower quadrant (RLQ)
2/3 distance from umbilicus to right ASIS
Overlies base of appendix typically
Most common site of maximum tenderness

Clinical Significance:

Point tenderness highly suggestive of appendicitis
Rebound tenderness indicates peritoneal irritation
Guarding indicates inflammation
Rovsing’s sign: LLQ palpation causes RLQ pain

Additional Assessment Findings:

Psoas sign: Pain with right hip extension
Obturator sign: Pain with internal rotation of flexed hip
Fever (usually low-grade initially)
Anorexia, nausea, vomiting
Migration of pain from periumbilical to RLQ

Complications to Prevent:

Perforation (increased risk after 24-48 hours)
Abscess formation
Peritonitis
Sepsis

Nursing Interventions:

NPO status
IV access and fluids
Pain assessment (avoid masking)
Antibiotic administration
Surgical preparation

Question 33: Infant Vision Assessment

Question: A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?

Answer: Presence of strabismus

Detailed Rationale: Strabismus at 6 months requires immediate intervention:

Normal Vision Development:

Strabismus normal until 3-4 months
Binocular vision develops by 4 months
Persistence beyond 4 months abnormal
6-month-old should have aligned eyes

Risks of Untreated Strabismus:

Amblyopia (lazy eye)
Loss of depth perception
Permanent vision loss in affected eye
Suppression of image from deviating eye
Social/developmental impacts

Assessment Techniques:

Corneal light reflex test
Cover-uncover test
Tracking assessment
Red reflex examination
Observation during play

Treatment Options:

Corrective lenses
Patching therapy (good eye)
Eye exercises
Surgery if severe
Early intervention critical

Time-Sensitive Nature:

Visual pathways developing rapidly
Critical period for binocular vision
Better outcomes with early treatment
Prevention of permanent deficits

Question 34: Neutropenia Precautions

Question: A nurse is caring for a preschooler who has neutropenia. Which of the following statements should the nurse make to the child’s guardians?

Answer: “Avoid using your child’s daycare center.”

Detailed Rationale: Protecting neutropenic children from infection requires environmental modifications:

Neutropenia Definition:

Absolute neutrophil count (ANC) <1500
Severe: ANC <500
Inability to fight bacterial/fungal infections
Common with chemotherapy

Daycare Avoidance Rationale:

High concentration of infectious agents
Young children have poor hygiene
Frequent respiratory and GI infections
Close contact promotes transmission
Unable to control environment

Other Places to Avoid:

Shopping malls/stores
Movie theaters
Public transportation
Indoor play areas
Swimming pools
Crowds in general

Home Precautions:

Limit visitors
Screen for illness
Hand hygiene critical
No fresh flowers/plants
Cooked foods only
Daily baths
Oral care QID

When to Seek Medical Care:

Fever >38°C (100.4°F)
Chills or sweating
Cough or breathing problems
Redness, swelling, drainage
Diarrhea or vomiting
Exposure to communicable disease

Question 35: Hyperkalemia Treatment Monitoring

Question: A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

Answer: Serum potassium level 4.1 mEq/L

Detailed Rationale: Monitoring electrolyte response to treatment:

Normal Potassium Range:

Adolescents: 3.4-4.7 mEq/L
Patient’s level: 4.1 mEq/L (within normal limits)
Indicates successful treatment

Sodium Polystyrene Sulfonate (Kayexalate) Mechanism:

Cation exchange resin
Exchanges sodium for potassium in intestine
Potassium bound to resin and excreted
Works in colon primarily
Takes 2-24 hours for effect

Administration Considerations:

Retention enema held 30-60 minutes
Can be given orally with sorbitol
Multiple doses may be needed
Monitor for sodium overload
Assess for constipation

Hyperkalemia Dangers:

Cardiac arrhythmias
Peaked T waves
Widened QRS
Ventricular fibrillation
Cardiac arrest

Additional Treatments:

Calcium gluconate (cardiac protection)
Insulin with glucose
Sodium bicarbonate
Albuterol nebulization
Dialysis if severe

Question 36: Droplet Precautions for Pertussis

Question: A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?

Answer: Initiate droplet precautions for the child

Detailed Rationale: Proper isolation prevents pertussis transmission:

Transmission Route:

Large respiratory droplets
Coughing, sneezing, talking
Travel 3-6 feet
Highly contagious (80-90% household transmission)
Most contagious in catarrhal stage

Droplet Precautions Components:

Private room (or cohort with same organism)
Surgical mask within 3 feet
Standard precautions plus droplet
Door may remain open
Special air handling not required

Clinical Stages:

Catarrhal (1-2 weeks): Most contagious, mild URI symptoms
Paroxysmal (2-8 weeks): Severe coughing fits, whooping
Convalescent (weeks-months): Gradual improvement

Isolation Duration:

5 days after starting antibiotics
21 days if untreated
Until 3 weeks after cough onset

Treatment:

Azithromycin or erythromycin
Supportive care
Oxygen as needed
Suctioning for thick secretions
Small frequent meals

Complications:

Pneumonia
Seizures
Encephalopathy
Apnea in infants
Death in young infants

Question 37: Dehydration Monitoring

Question: A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?

Answer: “I will monitor my child’s number of wet diapers.”

Detailed Rationale: Monitoring hydration status at home:

Wet Diaper Significance:

Direct measure of urine output
Indicates kidney perfusion
Reflects hydration status
Easy for parents to track
Objective measurement

Expected Output:

Minimum: 4-6 wet diapers/24 hours
Normal: 6-8 wet diapers/24 hours
Decreased output indicates ongoing dehydration
No output in 8 hours requires immediate care

Additional Monitoring:

Weight daily (same scale, time)
Tear production
Moist mucous membranes
Skin turgor
Activity level
Capillary refill

Rehydration Guidelines:

Oral rehydration solution (ORS)
Small frequent amounts
50-100 mL/kg over 4 hours for mild
Continue breastfeeding
BRAT diet when tolerated
Avoid sugary drinks

When to Return:

Decreased urine output
Lethargy/irritability
Dry mucous membranes
Sunken eyes/fontanel
Blood in stool
Persistent vomiting

Question 38: Diabetes Insipidus After Head Injury

Question: A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus?

Answer: Sodium 155 mEq/L

Detailed Rationale: Understanding DI pathophysiology after head trauma:

Sodium Level Interpretation:

Normal range: 136-145 mEq/L
Patient’s level: 155 mEq/L (hypernatremia)
Results from excessive water loss
Concentration of serum sodium

Diabetes Insipidus Mechanism:

Pituitary damage from head injury
Decreased ADH production/release
Inability to concentrate urine
Massive water loss
Dehydration and hypernatremia

Clinical Manifestations:

Polyuria (>2 mL/kg/hr)
Polydipsia (if conscious)
Dilute urine (specific gravity <1.005)
Dehydration signs
Altered mental status

Diagnostic Criteria:

Urine output >4 mL/kg/hr
Urine specific gravity <1.005
Urine osmolality <200 mOsm/kg
Serum osmolality >300 mOsm/kg
Hypernatremia

Management:

Fluid replacement (calculate deficit)
DDAVP (desmopressin)
Monitor I&O strictly
Frequent sodium levels
Daily weights
Neurological assessments

Question 39: Buck’s Traction Care

Question: A nurse is caring for a school-age child who is in Buck’s traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take?

Answer: Assess peripheral pulses once every 4 hours

Detailed Rationale: Neurovascular monitoring in traction patients:

Assessment Frequency:

Every 1 hour for first 24 hours
Every 4 hours after 24 hours
More frequent if concerns
Document findings

5 P’s of Neurovascular Assessment:

Pain: Increasing pain may indicate compartment syndrome
Pallor: Color changes indicate circulation issues
Pulselessness: Absent pulses require immediate intervention
Paresthesia: Tingling/numbness indicates nerve involvement
Paralysis: Late sign of neurovascular compromise

Buck’s Traction Specifics:

Skin traction type
Used for femur fractures pre-operatively
Weight limit: 5-7 pounds
Maintains alignment
Reduces muscle spasms

Additional Assessments:

Skin integrity under traction
Proper body alignment
Weight hanging freely
Ropes in pulley tracks
Pin sites if skeletal traction

Complications to Monitor:

Compartment syndrome
Nerve damage
Skin breakdown
DVT formation
Infection (skeletal)

Question 40: Physical Abuse Indicators

Question: A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?

Answer: Symmetric burns of the lower extremities

Detailed Rationale: Recognizing patterns indicative of abuse:

Symmetric Burn Patterns:

Suggests intentional immersion
“Stocking” or “glove” distribution
Clear demarcation lines
Absence of splash marks
Protected areas (held position)

Other Suspicious Burn Patterns:

Cigarette burns (circular, uniform depth)
Iron/curling iron shapes
Grid patterns (heating grates)
Rope burns (restraint)
Multiple burns in various healing stages

Additional Physical Abuse Indicators:

Bruises in various stages
Bruises in protected areas
Pattern injuries (belt, cord)
Bite marks
Fractures inconsistent with development
Retinal hemorrhages (shaking)

Behavioral Indicators:

Fear of specific person
Withdrawal or aggression
Delayed seeking medical care
Inconsistent history
Child’s story differs from parents’
Inappropriate knowledge of abuse

Nursing Responsibilities:

Mandatory reporting
Objective documentation
Photography if permitted
Body diagram documentation
Exact quotes from child/parent
Non-judgmental approach

Question 41: Bicycle Safety Education

Question: A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include?

Answer: The child should be able to stand on the balls of their feet when sitting on the bike

Detailed Rationale: Proper bike fit is essential for safety:

Correct Bike Sizing:

Seated: balls of feet touch ground
Standing over center bar: both feet flat
Prevents injury if sudden stop needed
Allows proper control
Reduces fall risk

Additional Bike Safety Education:

Helmet Requirements:

Properly fitted (2 fingers above eyebrows)
Snug but comfortable
Straps form “V” under ears
Replace after any crash
CPSC approved

Road Safety Rules:

Ride with traffic
Use hand signals
Obey traffic signs
Use bike lanes when available
Bright clothing/reflectors
No riding at dusk/dark

Bike Maintenance:

Check brakes before riding
Proper tire inflation
Chain lubrication
Reflectors intact
No loose parts

Developmental Considerations:

Under 10: sidewalk riding
Traffic education before street riding
Supervision based on maturity
No passengers on single bikes
No headphones while riding

Question 42: Preschool Developmental Milestones

Question: A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?

Answer: Cuts an outlined shape using scissors

Detailed Rationale: Fine motor development at 4 years:

Expected Fine Motor Skills:

Uses scissors to cut out shapes
Copies circles and squares
Draws person with 2-4 body parts
Uses fork and spoon well
Dresses/undresses independently

Other 4-Year Milestones:

Gross Motor:

Hops on one foot
Catches bounced ball
Stands on one foot >2 seconds
Climbs well

Language:

Tells stories
Uses future tense
Says name and address
Uses 5-6 word sentences

Cognitive:

Counts to 10
Names 4 colors
Understands same/different
Follows 3-part commands

Social:

Cooperative play
Shares with prompting
Shows affection to friends
Prefers playing with others

Red Flags:

Cannot jump in place
No interactive play
Ignores other children
Doesn’t use “me” and “you” correctly
Cannot retell favorite story

Questions 43-45: Additional Clinical Scenarios

Question 43: Post-Operative Appendectomy

Question: A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?

Answer: Absence of peristalsis

Detailed Rationale:

Expected Finding:

Paralytic ileus common post-operatively
Normal response to abdominal surgery
Bowel manipulation during surgery
Anesthesia effects
Inflammatory response

Duration:

Usually resolves in 24-72 hours
Gradual return of function
Bowel sounds return first
Then passing gas
Finally bowel movement

Assessment:

Auscultate all 4 quadrants
Document absence/presence
Monitor for distension
Assess for nausea
NPO until bowel sounds return

Interventions:

NG decompression if needed
Early ambulation
Advance diet slowly
Monitor for complications

Question 44: Emancipated Minor Rights

Question: A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take?

Answer: Have the adolescent sign a consent form for treatment

Detailed Rationale:

Emancipated Minor Status:

Legal adult for medical decisions
Can consent to all treatments
No parental involvement required
Same rights as adults

Criteria for Emancipation:

Marriage
Military service
Court decree
Living independently
Teenage parent

STI Treatment Rights:

Most states allow minors to consent
Even without emancipation
Confidential treatment
Partner notification services

Documentation:

Verify emancipation status
Document in medical record
Standard consent forms
Maintain confidentiality

Question 45: Digoxin Toxicity Recognition

Question: A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse’s priority?

Answer: Episodes of vomiting (3 episodes noted in nurses’ notes)

Detailed Rationale:

Priority Assessment:

Vomiting is early sign of digoxin toxicity
Life-threatening arrhythmias possible
Requires immediate intervention
Check digoxin level stat

Digoxin Toxicity Signs in Infants:

GI: Vomiting, poor feeding
Cardiac: Bradycardia, arrhythmias
Neuro: Lethargy, irritability
Visual: Not reported in infants

Risk Factors:

Narrow therapeutic range
Dehydration
Hypokalemia
Renal dysfunction
Drug interactions

Immediate Actions:

Hold next digoxin dose
Notify provider
Obtain digoxin level
Check electrolytes
Continuous cardiac monitoring
Prepare for possible Digibind

Question 46: Breastfeeding Pain Management

Question: A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant’s pain?

Answer: Allow the mother to breastfeed while the sample is being obtained

Detailed Rationale:

Non-Pharmacological Pain Management:

Breastfeeding provides multiple pain-relieving mechanisms
Sweet taste of breast milk activates endogenous opioids
Sucking provides distraction and comfort
Maternal contact reduces stress response
Skin-to-skin contact releases oxytocin

Evidence-Based Practice:

Studies show 30-50% reduction in pain scores
Decreased crying time
Faster return to baseline heart rate
Lower cortisol levels
Better than sucrose water alone

Procedure Technique:

Position infant comfortably at breast
Allow good latch before procedure
Perform heel stick while actively nursing
Continue breastfeeding after procedure
Monitor for adequate sample collection

Alternative Pain Management:

Pacifier with sucrose solution
Skin-to-skin contact
Swaddling
Gentle restraint
Combination approaches most effective

Benefits Beyond Pain Relief:

Maintains breastfeeding relationship
Reduces maternal anxiety
Promotes bonding
Decreases procedure time
Improves parent satisfaction

Question 47: Wilms’ Tumor Precautions

Question: A nurse is creating a plan of care for a preschooler who has Wilms’ tumor and is scheduled for surgery. Which of the following interventions should the nurse include?

Answer: Avoid palpating the abdomen when bathing the child before surgery

Detailed Rationale:

Critical Safety Measure:

Palpation can cause tumor rupture
Risk of cancer cell dissemination
Seeding to other organs
Converts localized to metastatic disease
Significantly worsens prognosis

Wilms’ Tumor Characteristics:

Most common renal malignancy in children
Peak age 3-4 years
Encapsulated but friable
Usually unilateral
Good prognosis if contained

“No Palpation” Protocol:

Post “Do Not Palpate Abdomen” signs
Inform all healthcare providers
Gentle handling during care
Minimize abdominal procedures
Careful during transport

Pre-Operative Care:

Measure abdominal girth daily (tape measure at same level)
Monitor for increasing size
Assess for hematuria
Blood pressure monitoring (renin production)
Emotional support for surgery

Post-Operative Considerations:

Monitor for bleeding
Assess remaining kidney function
Radiation/chemotherapy per staging
Long-term follow-up needed
Monitor for late effects

Question 48: Epidural Hematoma Management

Question: A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?

Answer: Implement seizure precautions for the infant

Detailed Rationale:

Seizure Risk with Epidural Hematoma:

Blood accumulation increases intracranial pressure
Brain tissue compression and irritation
Seizures common complication
Can occur at any time
May be first sign of deterioration

Seizure Precautions Implementation:

Padded side rails
Suction equipment at bedside
Oxygen ready
Airway management equipment
IV access maintained
Anti-epileptic drugs available

Epidural Hematoma Pathophysiology:

Arterial bleeding (usually middle meningeal)
Rapid accumulation of blood
Classic “lucid interval”
Rapid deterioration possible
Surgical emergency

Additional Interventions:

Neurological checks q15-30 minutes
HOB elevated 30 degrees
Maintain midline head position
Avoid hip flexion
Limit stimulation
Monitor ICP if device placed

Emergency Preparedness:

Rapid response team awareness
OR notification
Type and crossmatch
Family support
Documentation of changes

Question 49: Organ Donation Discussion

Question: A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first?

Answer: Explore the parents’ feelings and wishes regarding organ donation

Detailed Rationale:

Assessment First (Nursing Process):

Understanding parents’ perspectives essential
Cultural/religious beliefs impact decision
Emotional readiness varies
Previous discussions with child relevant
Family dynamics important

Therapeutic Communication:

Open-ended questions
Active listening
Acknowledge grief
Provide emotional support
Allow time for processing
Respect their decision

Timing Considerations:

After brain death confirmation
Separate from end-of-life discussion
Trained coordinator involvement
No pressure or coercion
Family-centered approach

Information to Provide (After Assessment):

Donation process
Which organs/tissues viable
No cost to family
No disfigurement for viewing
Can specify organ recipients
Follow-up support available

Support Resources:

Organ procurement organization
Chaplain services
Social work
Grief counseling
Support groups
Memorial options

Question 50: Pertussis Manifestations

Question: A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?

Answer: Dry, hacking cough

Detailed Rationale:

Characteristic Cough:

Starts as dry, hacking cough
Progresses to paroxysmal stage
Worse at night initially
“Whooping” sound after cough fits
Post-tussive vomiting common

Three Stages of Pertussis:

1. Catarrhal Stage (1-2 weeks):

Mild URI symptoms
Low-grade fever
Dry, hacking cough begins
Most contagious period

2. Paroxysmal Stage (2-8 weeks):

Severe coughing paroxysms
Inspiratory “whoop”
Cyanosis during coughing
Exhaustion after fits
Between fits, patient appears well

3. Convalescent Stage (weeks-months):

Gradual decrease in coughing
Susceptible to respiratory infections
“100-day cough”

Adolescent Presentation:

May lack classic “whoop”
Persistent cough main symptom
Often misdiagnosed as bronchitis
Source of infant infections

Diagnostic Confirmation:

PCR testing preferred
Culture (gold standard but slow)
Serology in later stages

Question 51: Time Concepts for Preschoolers

Question: A nurse is caring for a preschooler whose guardian is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their guardian will return?

Answer: “Your guardian will be back after you eat.”

Detailed Rationale:

Preschooler Time Understanding:

Abstract time concepts not developed
Cannot understand clock time
Hours/minutes meaningless
Need concrete references
Daily routines provide framework

Effective Time References:

Meals (breakfast, lunch, dinner)
Sleep times (nap, bedtime)
Activities (playtime, bath time)
TV shows they know
Routine events

Developmental Considerations:

Concrete operational thinking
Egocentric perspective
Immediate experience focus
Routine provides security
Predictability reduces anxiety

Separation Anxiety Management:

Acknowledge feelings
Provide comfort object
Maintain routines
Distraction activities
Positive reunion planning

Communication Strategies:

Simple, concrete language
Visual aids helpful
Repeat as needed
Calm, reassuring tone
Consistency important

Question 52: Osteomyelitis Detection

Question: A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication?

Answer: Erythrocyte sedimentation rate 18 mm/hr

Detailed Rationale:

ESR Interpretation:

Normal school-age: up to 10 mm/hr
Patient’s result: 18 mm/hr (elevated)
Non-specific inflammation marker
Suggests possible osteomyelitis

Osteomyelitis Risk Factors:

Open fracture (direct contamination)
Surgical hardware placement
Compromised blood flow
Delayed treatment
Inadequate debridement

Clinical Presentation:

Fever (may be low-grade)
Localized pain increasing
Erythema at surgical site
Limited range of motion
Possible drainage

Laboratory Findings:

Elevated ESR (early indicator)
Elevated CRP
Leukocytosis
Blood cultures (often negative)
Bone culture definitive

Management:

Long-term IV antibiotics (4-6 weeks)
Possible surgical debridement
Hardware removal consideration
Serial ESR/CRP monitoring
MRI for diagnosis

Complications if Untreated:

Chronic osteomyelitis
Growth disturbances
Pathological fractures
Sepsis
Joint destruction

Question 53: Sickle Cell Crisis Prioritization

Question: A nurse on a pediatric unit is caring for a school-age child. After reviewing the information in the child’s medical record, which of the following findings should the nurse address first? Complete the following sentence by using the list of options.

Answer: The nurse should first address the child’s oxygen saturation followed by the child’s pain.

Detailed Rationale:

Priority 1 – Oxygen Saturation:

Below 95% indicates hypoxia
Hypoxia worsens sickling
Creates vicious cycle
Can lead to acute chest syndrome
Life-threatening complication

Hypoxia Management:

Supplemental oxygen immediately
Continuous pulse oximetry
Incentive spirometry
Position for optimal expansion
Hydration to decrease viscosity

Priority 2 – Pain Management:

Pain score 8/10 indicates severe pain
Vaso-occlusive crisis causes ischemia
Undertreated pain causes stress
Stress worsens sickling
Multimodal approach needed

Pain Interventions:

Opioids (morphine, hydromorphone)
Around-the-clock dosing
PCA pump if appropriate
NSAIDs as adjunct
Non-pharmacological methods
Warm compresses (never cold)

Why This Order:

Airway/Breathing before comfort
Hypoxia immediately life-threatening
Pain severe but not immediately fatal
Both require urgent intervention
Treating hypoxia may reduce pain

Question 54: Post-Appendectomy Complications

Question: A nurse is caring for a school-age child following an appendectomy. After reviewing the information in the child’s medical record, which of the following findings should the nurse identify as a potential complication? Select the 3 findings from the child’s medical record that the nurse should identify as indications of a potential complication.

Answer:

WBC count (significantly elevated from baseline)
Abdomen assessment (rigid and distended)
Temperature (elevated above normal range)

Detailed Rationale:

Postoperative Infection Indicators:

WBC Count Elevation:

Significant increase from pre-op
Suggests ongoing infection
May indicate abscess formation
Peritonitis development possible
Requires immediate intervention

Abdominal Assessment:

Rigid, distended abdomen
Board-like rigidity suggests peritonitis
Increased pain concerning
May indicate:
- Abscess formation
- Bowel obstruction
- Peritonitis
- Wound dehiscence

Temperature Elevation:

Fever after first 24 hours abnormal
Low-grade expected initially (surgical stress)
Persistent/increasing fever concerning
Indicates infection process

Additional Assessment Needed:

Wound assessment for drainage
Character of any drainage
Bowel sounds presence
Nausea/vomiting
Pain characteristics

Interventions:

Notify surgeon immediately
Blood cultures
Broad-spectrum antibiotics
Possible CT scan
NPO status
Surgical consultation

Question 55: Physical Neglect Indicators

Question: A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect?

Answer: Poor personal hygiene

Detailed Rationale:

Physical Neglect Manifestations:

Poor hygiene (unchanged diapers, dirty clothing)
Inappropriate dress for weather
Consistent hunger
Unmet medical needs
Lack of supervision
Unsafe living conditions

Why Hygiene Indicates Neglect:

Toddlers dependent on caregivers
Cannot maintain own hygiene
Reflects lack of basic care
May indicate other neglect areas
Pattern more significant than isolated incident

Assessment Considerations:

Chronic vs. acute findings
Pattern of neglect
Developmental delays
Growth parameters
Behavioral indicators
Parent-child interaction

Other Neglect Types:

Medical (untreated conditions)
Educational (chronic absences)
Emotional (lack of affection)
Supervisory (left alone)

Nursing Actions:

Document objectively
Mandatory reporting
Collaborate with social services
Family assessment
Resource referrals
Follow-up care

Differential Considerations:

Poverty vs. neglect
Cultural practices
Parent capability
Support systems
Access to resources

Question 56: Glomerulonephritis vs HUS Assessment

Question: A nurse is caring for a preschooler who was recently admitted to a pediatric unit. The nurse is reviewing the information in the child’s electronic medical record (EMR). For each EMR finding, click to specify if the finding is consistent with nephrotic syndrome, acute poststreptococcal glomerulonephritis, or hemolytic uremic syndrome.

Answer:

Temperature: Consistent with acute poststreptococcal glomerulonephritis and hemolytic uremic syndrome
BUN level: Consistent with acute poststreptococcal glomerulonephritis and hemolytic uremic syndrome
Platelet count: Consistent with hemolytic uremic syndrome

Detailed Rationale:

Temperature Elevation:

Glomerulonephritis: Low-grade fever common from streptococcal infection
HUS: High fever possible, may cause hallucinations and lethargy
Nephrotic Syndrome: Typically afebrile unless secondary infection

BUN Elevation:

Both conditions: Indicate impaired kidney function
Glomerulonephritis: Glomerular inflammation affects filtration
HUS: Intravascular coagulation damages glomeruli
Reflects decreased GFR in both

Platelet Count:

HUS specific: Thrombocytopenia hallmark finding
Consumed in microthrombi formation
Part of classic triad (hemolytic anemia, thrombocytopenia, renal failure)
Not typically affected in glomerulonephritis

Disease Differentiation:

HUS: Preceded by diarrheal illness (E. coli O157:H7)
Glomerulonephritis: Follows streptococcal infection by 1-2 weeks
Nephrotic Syndrome: Massive proteinuria, edema, hypoalbuminemia

Question 57: Hemophilia Management

Question: A nurse on a pediatric unit is caring for a toddler with hemophilia A who fell at home. Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated?

Answer – Anticipated:

Administer factor VIII
Apply ice packs to affected joints
Administer morphine PRN pain

Answer – Contraindicated:

Perform passive range-of-motion exercises

Detailed Rationale:

Factor VIII – Anticipated:

Essential for hemophilia A treatment
Replaces deficient clotting factor
Controls active bleeding
Prevents bleeding progression
Dosing based on severity and site

Ice Application – Anticipated:

Vasoconstriction reduces bleeding
Decreases swelling and pain
Apply 15-20 minutes at a time
Use barrier to protect skin
Part of RICE protocol (without compression)

Morphine – Anticipated:

Severe pain expected with hemarthrosis
Opioids appropriate for acute episodes
Avoid NSAIDs (affect platelet function)
Acetaminophen for mild pain
Pain control improves mobility

Passive ROM – Contraindicated:

Can worsen bleeding
Traumatic to inflamed joint
Wait until bleeding controlled
Active ROM when ready
Physical therapy after acute phase

Additional Management:

Elevate affected limb
Immobilize during acute phase
Monitor for compartment syndrome
Prophylactic factor for severe hemophilia
Genetic counseling for family

Question 58: Laryngotracheobronchitis Improvement

Question: A nurse is caring for an 8-month-old infant with moderate acute laryngotracheobronchitis (LTB). Upon evaluation of the infant’s status at 0630, the nurse should identify which of the following as signs of improvement?

Answer:

Infant is sleeping in parent’s arms
SpO2 is 96% with 100% cool mist oxygen via blow-by
Breath sounds are present and equal bilaterally in the bases
Infant voided 34 mL

Detailed Rationale:

Sleeping in Parent’s Arms:

Previously restless and irritable despite holding
Now calm and sleeping
Indicates decreased respiratory distress
Improved comfort level
Reduced anxiety and hypoxia

Improved Oxygen Saturation:

Rose from 89% to 96%
Within normal range
Indicates better gas exchange
Reduced airway obstruction
Effective treatment response

Improved Breath Sounds:

Previously diminished
Now present bilaterally
Indicates improved air movement
Reduced airway edema
Better ventilation

Urine Output:

No void in >12 hours on admission
34 mL output shows hydration improving
Indicates adequate perfusion
Reduced insensible losses
Overall improvement

LTB Management Success Indicators:

Decreased stridor
Improved color
Reduced retractions
Calmer demeanor
Tolerating oral fluids

Question 59: SIADH Recognition

Question: A nurse is caring for a 15-year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Answer: Mental confusion

Detailed Rationale:

SIADH Pathophysiology:

Head injury affects pituitary/hypothalamus
Excessive ADH secretion
Water retention without sodium
Dilutional hyponatremia
Cerebral edema development

Mental Confusion Mechanism:

Hyponatremia primary cause
Sodium <135 mEq/L
Brain cells swell
Neurological symptoms appear
Progressive deterioration possible

SIADH Clinical Features:

Decreased urine output
Concentrated urine (high specific gravity)
Weight gain without edema
Hyponatremia
Low serum osmolality
High urine osmolality

Neurological Progression:

Headache
Confusion
Irritability
Seizures
Coma

Management:

Fluid restriction (primary treatment)
3% saline if severe
Slow correction essential
Monitor sodium q2-4h
Daily weights
Strict I&O

Complications:

Central pontine myelinolysis (rapid correction)
Seizures
Permanent neurological damage
Death if untreated

Question 60: Cheiloplasty Post-Operative Care

Question: A nurse is providing discharge teaching to the parents of a 3-month-old infant following a cheiloplasty. Which of the following instructions should the nurse include?

Answer: “Apply a thin layer of antibiotic ointment on your baby’s suture line daily for the next 3 days.”

Detailed Rationale:

Wound Care Protocol:

Antibiotic ointment x 3 days prevents infection
Then petroleum jelly for several weeks
Keeps suture line moist
Promotes healing
Reduces scar formation

Cheiloplasty (Cleft Lip Repair) Care:

Suture Line Management:

Gentle cleaning with saline after feeds
Pat dry (don’t rub)
Apply ointment as directed
Monitor for signs of infection
Avoid disrupting sutures

Feeding Modifications:

Special bottles or syringes
Avoid regular nipples/pacifiers
Breastfeeding may be allowed
Upright positioning
Frequent burping

Arm Restraints:

Elbow restraints prevent touching
Remove periodically for ROM
One at a time with supervision
Continue until sutures removed
Usually 5-7 days

Pain Management:

Acetaminophen as prescribed
Comfort measures
Minimize crying (stress on sutures)
Gentle handling

Follow-up Care:

Suture removal timing
Scar management
Speech therapy referral
Future surgical planning
Dental follow-up

Complications to Monitor:

Dehiscence
Infection
Bleeding
Poor feeding
Excessive scar formation