Pediatric Nursing NCLEX Challenge Exam:
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Part 1
1. Molly, with suspected rheumatic fever, is admitted to
the pediatric unit. When obtaining the child’s history, the
nurse considers which information to be most important?
A. A fever that started 3 days ago
B. Lack of interest in food
C. A recent episode of pharyngitis
D. Vomiting for 2 days
A recent episode of pharyngitis is the most important
factor in establishing the diagnosis of rheumatic fever.
Activation of the innate immune system begins with a
pharyngeal infection that leads to the presentation of S.
pyogenes antigens to T and B cells. CD4+ T cells are
activated and production of specific IgG and IgM
antibodies by B cells ensues (Cunningham,
Pathogenesis of group A streptococcal infections, 2000).
Option A: The most common presenting features of
ARF are fever (>90% of patients) and arthritis (75% of
patients). The most serious manifestation is carditis
(>50% of patients) because it can lead to chronic
rheumatic heart disease—while all other clinical features
fully resolve, often within weeks.
Option B: The child with ARF may exhibit a lack of
interest in food, but this cannot be specific only to ARF.
The main clinical manifestation of ARF carditis reflects
the involvement of the endocardium, which presents as
valvulitis of the mitral valve (mitral regurgitation) and,
less frequently, of the aortic valve (aortic regurgitation).
Option D: Although the child may have a history of
vomiting, this finding is not specific to rheumatic fever. A
number of other clinical features are often observed in
patients with ARF but are not included as manifestations
in the Jones Criteria, including lethargy, abdominal pain,
and epistaxis, as well as rapid sleeping pulse rate and
tachycardia out of proportion to fever.
2. The nurse is aware that the most common
assessment finding in a child with ulcerative colitis is:
A. Intense abdominal cramps
B. Profuse diarrhea
C. Anal fissures
D. Abdominal distention
The most common assessment finding in a child with
ulcerative colitis is profuse diarrhea. The main symptom
of ulcerative colitis is bloody diarrhea, with or without
mucus. Other symptoms include blood in the toilet, on
toilet paper, or in the stool. Characteristically, it involves
inflammation restricted to the mucosa and submucosa of
the colon. Typically, the disease starts in the rectum and
extends proximally in a continuous manner.
Option A: Ulcerative colitis causes intense abdominal
cramps. Associated symptoms also include urgency or
tenesmus, abdominal pain, malaise, weight loss, and
fever, depending on the extent and severity of the
disease. The onset of the disease is typically gradual,
and patients will likely experience periods of
spontaneous remission and subsequent relapses.
Option C: Ulcerative colitis causes anal fissures.
are some extraintestinal manifestations (EIMs) that are
also present in 10% to 30% of patients with ulcerative
colitis. Extraintestinal manifestations associated with
disease activity include episcleritis, scleritis, and uveitis,
peripheral arthropathies, erythema nodosum, and
pyoderma gangrenosum.
Option D: Abdominal distensions are more common in
Crohn’s disease. Patients with flare-ups of Crohn’s
disease typically present with abdominal pain (right
lower quadrant), flatulence/bloating, diarrhea (can
include mucus and blood), fever, weight loss, anemia. In
severe cases, perianal abscess, perianal Crohn’s
disease, and cutaneous fistulas can be seen.
3. When developing a plan of care for a hospitalized
child, nurse Mary knows that children in which age
group is most likely to view illness as a punishment for
misdeeds?
A. Infancy
B. Preschool age
C. School age
D. Adolescence
Preschool-age children are most likely to view illness as
a punishment for misdeeds. When children in this age
group become seriously ill, they may think it’s
punishment for something they did or thought about.
They don’t understand how their parents could not have
protected them from this illness.
Option A: Separation anxiety, although seen in all age
groups, is most common in older infants. Keeping a
consistent routine is important for a baby and their
caregivers. Because babies can’t talk about their needs,
fear is often expressed by crying.
Option C: Fear of the unknown, loss of control, and
separation from family and friends can be the school-
aged child’s main sources of anxiety and fear related to
death. They may fear their own death because of the
uncertainty of what happens to them after they die.
Option D: Fear of death is typical of adolescents.
Adolescents also fear mutilation. Most teens are starting
to establish their identity, independence, and relation to
peers. The main theme in teens is feeling immortal or
being exempt from death. Their realization of their own
death threatens all of these objectives.
4. A female child, age 6, is brought to the health clinic
for a routine checkup. To assess the child’s vision, the
nurse should ask:
A. “Do you have any problems seeing different colors?”
B. “Do you have trouble seeing at night?”
C. “Do you have problems with glare?”
D. “How are you doing in school?”
A child’s poor progress in school may indicate a visual
disturbance. Most children do not have 20/20 vision until
after six years of age, but at any age, visual acuity
should be approximately equal between the eyes. The
Multi-Ethnic Pediatric Eye Disease Study provided
updated norms for visual acuity in children two and a
half to six years of age.
Option A: This option is more appropriate to ask when
assessing vision in a geriatric patient. The American
Academy of Ophthalmology recommends the use of an
eye chart by three years of age. Picture charts (Lea or
Allen) or matching charts (HOTV) can be used in
preliterate children, and letter charts (Snellen) can be
used in literate children.
Option B: This option is more appropriate to ask when
assessing vision in a geriatric patient. Vision screening
in children is an ongoing process with different
components occurring at each well-child visit. It can
reveal conditions commonly treated in primary care and
can aid in the discussion of visual concerns with parents
or caregivers.
Option C: This option is more appropriate to ask when
assessing vision in a geriatric patient. The American
Academy of Family Physicians and the U.S. The
Preventive Services Task Force recommends vision
screening at least once in all children three to five years
of age (B recommendation).
5. Hannah, age 12, is 7 months pregnant. When
teaching parenting skills to an adolescent, the nurse
knows that which teaching strategy is least effective?
A. Providing a one-on-one demonstration and
requesting a return demonstration, using a live infant
model
B. Initiating a teenage parent support group with first
and second-time mothers
C. Using audiovisual aids that show discussions of
feelings and skills
D. Providing age-appropriate reading materials
Because adolescents absorb less information through
reading, providing age-appropriate reading materials is
the least effective way to teach parenting skills to an
adolescent. The Adolescent Family Life (AFL)
demonstration projects, organized through the Office of
Adolescent Pregnancy Programs (OAPP), are aimed to
support young families through social support and
medical care.
Option A: Adding a structured, comprehensive
parenting curriculum to an AFL-funded teen-tot model
would increase parenting self-esteem and reduce
parenting attributes associated with child maltreatment,
maternal depression, and repeat pregnancy over a 36-
month follow-up.
Option B: The AFL funding required programs to deliver
10 core services, including pregnancy testing, adoption
counseling, preventive and prenatal referrals for teens,
nutritional counseling, well infant care, sexually
transmitted infection screening, family life counseling,
educational or vocational services, mental health
services, and referrals for family planning.
Option C: The other options engage more than one of
the senses and therefore serve as effective teaching
strategies. On the basis of competency learning
principles, the intervention used informational lectures,
vignette discussions, reflection, and interactive “practice”
activities.
6. A 5-year-old girl Hannah is recently diagnosed with
Kawasaki disease. Apart from the identified symptoms
of the disease, she may also likely develop which of the
following?
A. Sepsis
B. Meningitis
C. Mitral valve disease
D. Aneurysm formation
Kawasaki disease is a rare childhood illness that affects
the blood vessels. 20% to 25% of children can develop
aneurysm formation if not intervened. Treatment
depends on the degree of the disease but is often
immediate treatment with IV gamma globulin or aspirin.
Corticosteroids can sometimes lessen impending
complications. Children who experience the disease
usually need lifelong follow-up appointments to keep an
eye on heart health.
Option A: Over weeks and months, wall thickening of
the coronary aneurysms can lead to stenosis and
thrombus formation which can result in myocardial
infarction (MI), rupture, ischemia-related dysrhythmias,
or death.
Option B: The greatest risk of these cardiac
complications is during the period of thrombocytosis.
Small coronary aneurysms may resolve in 60% of cases
in the later convalescent-phase when inflammatory
markers return to normal.
Option C: Kawasaki disease (KD), also known by the
name mucocutaneous lymph node syndrome, is an
acute, self-limited medium vessel vasculitis that has a
predilection for the coronary arteries. It is the leading
cause of acquired heart disease in developed nations
and is slowly bypassing rheumatic heart disease in
developing countries.
7. Question1 point(s)
When creating a teaching program for the parents of
Jessica who is diagnosed with pulmonic stenosis (PS),
Nurse Alex would keep in mind that this disorder
involves which of the following?
A. A single vessel arising from both ventricles
B. Obstruction of blood flow from the left ventricle
C. Obstruction of blood flow from the right ventricle
D. Return of blood to the heart without entry to the left
atrium
PS refers to an obstruction of blood flow from the right
ventricle. Pulmonic stenosis is a defect of the pulmonic
valve in which the valve is stiffened, causing an
obstruction to flow. This disease is typically congenital,
benign, and diagnosed in pediatric patients with
potentially curative treatments.
Option A: Truncus arteriosus involves a single vessel
arising from both ventricles. Persistent truncus
arteriosus (TA) is a rare, congenital, cyanotic heart
defect characterized by a ventricular septal defect
(VSD), a single truncal valve, and a common ventricular
outflow tract (OT).
Option B: A physical exam may reveal multiple signs of
pulmonic stenosis, depending on severity and
practitioner skill. Cardiac examination may reveal a left
parasternal heave, secondary to right ventricular
hypertrophy. Auscultation at the left upper sternal border
may reveal a systolic ejection murmur radiating to the
back.
Option D: Total anomalous pulmonary venous
communications involve the return of blood to the heart
without entry into the left atrium and obstruction of blood
flow from the left ventricle.
8. Which of the following would Nurse Tony suppose to
regard as a cardinal manifestation or symptom of
digoxin toxicity to his patient Clay diagnosed with heart
failure?
A. Headache
B. Respiratory distress
C. Extreme bradycardia
D. Constipation
Extreme bradycardia is a cardinal sign of digoxin
toxicity. Increased intracellular calcium from the
poisoning of the Na-K transporter and AV nodal
blockade from increased vagal tone are the primary
causes of digoxin toxicity. The former leads to increased
automaticity and inotropy; the latter leads to decreased
dromotropy.
Option A: Elderly patients frequently will present with
vague symptoms, such as dizziness and fatigue. The
most important historical detail in evaluating a random
digoxin level is the time of the last dose.
Option B: Patients also may report visual symptoms,
which classically present as a yellow-green
discoloration, and cardiovascular symptoms, such as
palpitations, dyspnea, and syncope. Digoxin may
improve the quality of life in CHF patients, but it does not
confer a mortality benefit, and its narrow therapeutic
index limits its utility.
Option D: Gastrointestinal upset is the most common
symptom of digoxin toxicity. Derived from the foxglove
plant (Digitalis spp.), digoxin is a cardiac glycoside that
historically was used for “dropsy” (edema) and is
currently used as an inotrope to improve systolic
dysfunction in patients with congestive heart failure
(CHF) and as an atrioventricular nodal blocking agent
for managing atrial tachydysrhythmias.
9. It is considered as the bluntly rounded portion of the
heart.
A. Base
B. Pericardium
C. Aorta
D. Apex
The blunt, rounded point of the heart is the apex. The
apex (the most inferior, anterior, and lateral part as the
heart lies in situ) is located on the midclavicular line, in
the fifth intercostal space. It is formed by the left
ventricle. The general structure of the heart is quite
uniform in healthy individuals. However, some variations
do occur.
Option A: The larger, flat portion at the opposite is the
base. The base of the heart, the posterior part, is formed
by both atria, but mainly the left. The heart is arranged
more horizontally in the chest in short and obese
individuals, while it is more vertical in tall and thin
people. An athlete’s heart may be physically larger.
Option B: The pericardium is also called the pericardial
sac. It has a fibrous outer layer and a thin inner layer
that surrounds the heart. The pericardium is a fibrous
sac that encloses the heart and great vessels. It keeps
the heart in a stable location in the mediastinum,
facilitates its movements, and separates it from the
lungs and other mediastinal structures. It also supports
physiological cardiac function.
Option C: The aorta is the largest artery that carries
blood from the left ventricle to the body. The aorta is the
largest vessel within the human body. It originates from
the left ventricle of the heart anterior to the pulmonary
artery before arching posteriorly and descending along
the posterior mediastinum.
10. Which of the following disorders leads to cyanosis
from deoxygenated blood entering the systemic arterial
circulation?
A. Aortic stenosis (AS)
B. Coarctation of aorta
C. Patent ductus arteriosus (PDA)
D. Tetralogy of Fallot
Tetralogy of Fallot consists of four major anomalies:
ventricular septal defect, right ventricular hypertrophy,
pulmonic stenosis (PS), aorta overriding the ventricular
septal defect. PS impedes the flow of blood to the lungs,
causing increased pressure in the right ventricle, forcing
deoxygenated blood through the septal defect in the left
ventricle. As a result of this decreased pulmonary flow,
deoxygenated blood is shunted into the systemic
circulation. The increased workload on the right ventricle
causes hypertrophy. The overriding aorta receives blood
from both the right and left ventricles. This is the
definition of a defect with decreased pulmonary blood
flow where unoxygenated blood is shunted into the
systemic circulation.
Option A: Aortic stenosis is a common valvular
disorder, especially in the elderly population, causing left
ventricular outflow obstruction. Etiologies include
congenital (bicuspid/unicuspid), calcific, and rheumatic
disease.
Option B: Coarctation of the aorta is an obstructive
defect where obstruction, not shunting, is the problem.
Coarctation of the aorta is a narrowing of the aorta, most
commonly occurring just beyond the left subclavian
artery. However, it can occur in various other locations
of the aortic arch or even in the thoracic or abdominal
aorta.
Option C: With PDA, blood flows from the aorta through
the PDA and back to the pulmonary artery and lungs
(shunting of oxygenated blood to the pulmonic system),
causing increased pulmonary vascular congestion.
11. Betty is a 9-year-old girl diagnosed with cystic
fibrosis. Which of the following must Nurse Archie keep
in mind when developing a care plan for the child?
A. Pulmonary secretions are abnormally thick.
B. Elevated levels of potassium are found in sweat.
C. CF is an autosomal dominant hereditary disorder.
D. Obstruction of the endocrine glands occurs.
CF is identified by abnormally thick pulmonary
secretions. Researchers now know that cystic fibrosis is
an autosomal recessive disorder of exocrine gland
function most commonly affecting persons of Northern
European descent at a rate of 1 in 3500. It is a chronic
disease that frequently leads to chronic sinopulmonary
infections and pancreatic insufficiency. The most
common cause of death is end-stage lung disease.
Option B: Diagnosis of CF is based on elevated
chloride levels detected in sweat. High levels of salt in
the sweat of patients with cystic fibrosis suggested an
abnormality in electrolyte transport from the sweat
gland. Quinton postulated that sweat ducts in these
patients were impermeable to chloride.
Option C: It is a chronic, inherited disorder, particularly
an autosomal recessive hereditary disorder concerning
the exocrine, not endocrine glands. In 1949, Lowe et al.
postulated that cystic fibrosis must be caused by a
genetic defect from the autosomal recessive pattern of
inheritance of the disease.
Option D: The thick mucus blocks the exocrine glands.
Further studies led to the hypothesis that the faulty
chloride channel must be situated in the apical
membranes of the lung surface or glandular epithelium
to explain the respiratory and systemic organ failure
associated with cystic fibrosis.
12. Alice is rushed to the emergency department during
an acute, severe prolonged asthma attack and is
unresponsive to usual treatment. The condition is
referred to as which of the following?
A. Status asthmaticus
B. Reactive airway disease
C. Intrinsic asthma
D. Extrinsic asthma
Status asthmaticus is an acute, prolonged, severe
asthma attack that is unresponsive to usual treatment.
Typically, the child requires hospitalization. One of the
most common causes of emergency room visits in the
United States is status asthmaticus, an acute, emergent
episode of bronchial asthma that is poorly responsive to
standard therapeutic measures.
Option B: Reactive airway disease is another general
term for asthma. In children, the diagnosis of RAD
(reactive airway disease) or recurrent WARIs (wheezing-
associated respiratory infections) often precede a formal
diagnosis of asthma.
Option C: Intrinsic is a term used to denote internal
precipitating factors, such as viruses. In intrinsic asthma,
IgE is usually only involved locally, within the airway
passages. The airways become more and more narrow,
resulting in an asthma attack. Unlike extrinsic asthma,
which is triggered by commonly known allergens,
intrinsic asthma may be triggered by a wide range of
non-allergy-related factors.
Option D: Extrinsic is a term used to denote external
precipitating factors, such as allergens. Extrinsic asthma
is more common than intrinsic asthma. In extrinsic
asthma, symptoms are triggered by an allergen (such as
dust mites, pet dander, pollen, or mold). The immune
system overreacts, producing too much of a substance
(called IgE) throughout the body. It’s the IgE that triggers
an extrinsic asthma attack.
13. Baby Melody is a neonate who has a very-low-birth-
weight. Nurse Josie carefully monitors inspiratory
pressure and oxygen (O2) concentration to prevent
which of the following?
A. Meconium aspiration syndrome
B. Bronchopulmonary dysplasia (BPD)
C. Respiratory syncytial virus (RSV)
D. Respiratory distress syndrome (RDS)
Close monitoring of inspiratory pressure and O2
concentration is necessary to prevent BPD, which is
related to the use of high inspiratory pressures and O2
concentrations especially in very-low-birth-weight and
extremely low-birth-weight neonates with lung disorders.
Injury from mechanical ventilation and reactive oxygen
species to premature lungs in the presence of antenatal
factors predisposing the lungs to BPD form the basis of
pathogenesis of BPD in preterm neonates.
Option A: Meconium aspiration syndrome is a
respiratory disorder created by the aspiration of
meconium in the perinatal period. Meconium aspiration
syndrome (MAS) is the neonatal respiratory distress that
occurs in a newborn in the context of MASF when
respiratory symptoms cannot be attributed to another
etiology.
Option C: RSV is a group of viruses that cause
respiratory tract infections, such as bronchiolitis and
pneumonia. The most common clinical scenario
encountered in RSV infection is an upper respiratory
infection, but RSV commonly presents in young children
as bronchiolitis, a lower respiratory tract illness with
small airway obstruction, and can rarely progress to
pneumonia, respiratory failure, apnea, and death.
Option D: RDS, a disorder caused by lack of surfactant,
usually is found in premature neonates. RDS primarily
affects preterm neonates, and infrequently, term infants.
The incidence of RDS is inversely proportional to the
gestational age of the infant, with more severe disease
in the smaller and more premature neonates.
14. Which of the following instructions should Nurse
Cheryl include in her teaching plan for the parents of
Reggie with otitis media?
A. Placing the child in the supine position to bottle-feed
B. Giving prescribed amoxicillin (Amoxil) on an empty
stomach
C. Cleaning the inside of the ear canals with cotton
swabs
D. Avoiding contact with people who have upper
respiratory tract infections
Otitis media is commonly precipitated by an upper
respiratory tract infection. Therefore, children prone to
otitis should avoid people known to have an upper
respiratory tract infection. Acute otitis media is the
second most common pediatric diagnosis in the
emergency department following upper respiratory
infections. Although otitis media can occur at any age, it
is most commonly seen between the ages of 6 to 24
months.
Option A: A bottle-fed child should be fed in an upright
position because feeding the child in the supine position
may actually precipitate otitis by allowing the formula to
pool in the pharyngeal cavity. Infants with otitis media
should be breastfed whenever possible, as breast milk
contains immunoglobulins that protect infants from
foreign pathogens in key phases of early extra-uterine
life.
Option B: Amoxicillin, when prescribed, should be given
with food to prevent stomach upset. If there is clinical
evidence of suppurative AOM, however, oral antibiotics
are indicated to treat this bacterial infection, and high-
dose amoxicillin or a second-generation cephalosporin
are first-line agents.
Option C: Cotton swabs can cause injuries such as
tympanic perforation. They may be used to clean the
outer ear, but they should never be inserted into the ear
canal.
15. When assessing a child’s cultural background, the
nurse in charge should keep in mind that:
A. Heritage dictates a group’s shared values
B. Physical characteristics mark the child as part of a
particular culture
C. Cultural background usually has little bearing on a
family’s health practices
D. Behavioral patterns are passed from one
generation to the next
A family’s behavioral patterns and values are passed
from one generation to the next. Pediatric health care
providers must be aware of the demographic trends and
be culturally competent to deliver the safest, highest
quality care possible to children of widely differing
groups.
Option A: Although heritage plays a role in culture, it
does not dictate a group’s shared values and its effect
on culture is weaker than that of behavioral patterns. In
addition to language differences, cultural differences
regarding nonverbal communication can create
communication barriers between a child, family and the
health care provider.
Option B: Physical characteristics do not indicate a
child’s culture. Folk illnesses often do not have a
corresponding illness from a biomedical or scientific
perspective and may not be perceived as an illness or
affliction by another cultural group.
Option C: Cultural background commonly plays a major
role in determining a family’s health practices. Health
and health care disparities are inextricably linked;
cultural competence on the part of the health care
provider is necessary to minimize and ultimately
eliminate any differences in quality of health care.
16. Dustin who was diagnosed with Hirschsprung’s
disease has a fever and watery explosive diarrhea.
Which of the following would Nurse Joyce do first?
A. Administer an antidiarrheal.
B. Notify the physician immediately.
C. Monitor the child every 30 minutes.
D. Nothing. (These findings are common in
Hirschsprung's disease.)
For the child with Hirschsprung’s disease, fever and
explosive diarrhea indicate enterocolitis, a life-
threatening situation. Therefore, the physician should be
notified directly. Further important pointers in the history
of patients with suspected HD include clinical features of
Hirschsprung’s associated enterocolitis (HAEC), multiple
episodes of overflow constipation, and soft distended
abdomen.
Option A: Generally, because of intestinal obstruction
and inadequate propulsive intestinal movement,
antidiarrheals are not used to treat Hirschsprung’s
disease. The diagnosis of Hirschsprung disease (HD)
almost exclusively demands surgical intervention.
Pediatric health care providers should possess a
comprehensive understanding of the most popular
surgical procedures to assist the bridging referral phase
between the surgeon and the patient’s family.
Option C: The child is acutely ill and requires
intervention, with monitoring more frequently than every
30 minutes. Parents should be aware of any suspicious
symptoms suggestive of HD, including delay in the
passage of meconium for more than 48 hours during the
neonatal period. Moreover, non-specific symptoms,
including constipation, abdominal distention, reflux,
nausea, vomiting, and diarrhea, should also raise
suspicion.
Option D: Hirschsprung’s disease typically presents
with chronic constipation. Several points in the history
and physical examination of HD as one of the differential
diagnosis of neonatal bowel obstruction include (1)
abnormal maternal amniotic fluid indexes including
polyhydramnios, (2) vomiting and specifically bilious
emesis, (3) obstipation, which might present with failure
to pass meconium in the first 48 hours of life and (4)
abdominal distention.
17. Which of the following applies to the defect emerging
from residual peritoneal fluid confined within the lower
segment of the processus vaginalis?
A. Inguinal hernia
B. Incarcerated hernia
C. Communicating hydrocele
D. Noncommunicating hydrocele
With a noncommunicating hydrocele, most commonly
seen at birth, residual peritoneal fluid is trapped within
the lower segment of the processus vaginalis (the tunica
vaginalis). There is no communication with the
peritoneal cavity and the fluid usually is absorbed during
the first months after birth.
Option A: An inguinal hernia arises from the incomplete
closure of the processus vaginalis leading to the descent
of an intestinal portion. An inguinal hernia is an opening
in the myofascial plain of the oblique and transversalis
muscles that can allow for herniation of intra abdominal
or extraperitoneal organs.
Option B: Incarceration occurs when the hernia
becomes tightly caught in the hernia sac. At times an
inguinal hernia can present with severe pain or
obstructive symptoms caused by incarceration or
strangulation of the hernia sac contents. Femoral
hernias should always be repaired as they have a high
risk of incarceration.
Option C: A communicating hydrocele usually is
associated with an inguinal hernia because the
processus vaginalis remains open from the scrotum to
the abdominal cavity. The tunica vaginalis is a potential
space for fluid to accumulate, provided the proximal
portion of processus vaginalis remains patent and
results in free communication with the peritoneal cavity,
leading to congenital hydrocele.
18. Mr. and Ms. Byers’ child failed to pass meconium
within the first 24 hours after birth; this may indicate
which of the following?
A. Celiac disease
B. Intussusception
C. Hirschsprung's disease
D. Abdominal-wall defect
Failure to pass meconium within the first 24 hours after
birth may be a sign of Hirschsprung’s disease, a
congenital anomaly resulting in mechanical obstruction
due to weak motility in an intestinal segment. History of
the colonic obstruction, which might occur during the
early neonatal period till adulthood, along with failure to
pass meconium during the first 48 hours of the life,
which presents in up to 90% of the affected patients, is
highly compatible with the impression of HD.
Option A: Celiac disease, also known as gluten-
sensitive enteropathy, is an autoimmune disease of the
small intestine. Celiac disease is a condition in which the
body responds to gluten with an inappropriate immune
response causing small intestinal inflammation and
damage.
Option B: Intussusception is a condition in which part of
the intestine folds into the section next to it.
Intussusception usually involves the small bowel and
rarely the large bowel. Symptoms include abdominal
pain which may wax and wane, vomiting, bloating, and
bloody stool.
Option D: Failure to pass meconium is not connected
with abdominal wall defect. Gastroschisis is a
paraumbilical abdominal wall defect associated with
protrusion of the bowel through the defect. A membrane
does not cover the bowel exposed in utero and, as a
result, may be matted, dilated, and covered with a
fibrinous inflammatory rind.
19. Steve is diagnosed with celiac disease and
experiences celiac crisis secondary to upper respiratory
tract infection; which of the following would Nurse Nancy
expect to assess?
A. Lethargy
B. Weight gain
C. Respiratory distress
D. Watery diarrhea
Episodes of celiac crises are precipitated by infections,
ingestion of gluten, prolonged fasting, or exposure to
anticholinergics. Celiac crisis is typically characterized
by severe watery diarrhea. Celiac crisis is a life-
threatening syndrome in which patients with celiac
disease have profuse diarrhea and severe metabolic
disturbances.
Option A: Irritability, rather than lethargy, is more likely.
Clinically it is characterized by severe diarrhea,
dehydration, and metabolic disturbances including
hypokalemia, hyponatremia, hypocalcemia,
hypomagnesemia, and hypoproteinemia.
Option B: Because of the fluid loss associated with
severe watery diarrhea, the child’s weight is more likely
to be decreased. In childhood, failure to thrive is an
important aspect of history, while in adulthood the
corresponding symptom would be unexplained weight
loss.
Option C: Respiratory distress is unlikely in a routine
upper respiratory tract infection. Symptoms from other
than gastrointestinal systems include recurrent aphthous
ulcers in the mouth, iron deficiency anemia, ataxia,
chronic headaches, and delayed menarche.
20. In pediatric gastroesophageal reflux disease
(GERD), the immaturity of lower esophageal sphincter
function is manifested by frequent transient lower
esophageal relaxations, which result in retrograde flow
of gastric contents into the esophagus. Which statement
about the esophagus is true? Select all that apply.
A. It is a cartilaginous tube.
B. It has upper and lower sphincters.
C. It lies anterior to the trachea.
D. It extends from the nasal cavity to the stomach.
E. It is a highway for food and drinks to travel along
to make it to the stomach.
F. All statements describe the esophagus.
Upper and lower esophageal sphincters, located at the
upper and lower ends of the esophagus, respectively,
regulate the movement of food into and out of the
esophagus. If the mouth is the gateway to the body,
then the esophagus is a highway for food and drink to
travel along to make it to the stomach.
Option A: The esophagus is a muscular tube, lined with
moist stratified squamous epithelium. The esophagus is
a muscular channel that carries food from the pharynx to
the stomach. It starts with the upper esophageal
sphincter, formed in part by the cricopharyngeus
muscle, and ends with the lower esophageal sphincter,
surrounded by the crural diaphragm.
Option C: It lies anterior to the vertebrae and posterior
to the trachea within the mediastinum. Additionally, the
trachea and the diaphragm closely neighbor the
esophagus, with the former being anterior to it and the
latter surrounding the LES through its crural part.
Option D: It extends from the pharynx to the stomach. It
is about 25 centimeters (cm) long. The esophagus
serves as a conduit for the transportation of a bolus from
the pharynx to the stomach. Thus, events occurring
upstream, in the mouth, and downstream, in the
stomach impact the esophagus.
21. Nurse Elena is handling a 7-year-old child who has
cystitis. Which of the following would Nurse Elena
expect when assessing the child?
A. Dysuria
B. Costovertebral tenderness
C. Flank pain
D. High fever
Dysuria is a symptom of a lower urinary tract infection
(UTI) such as cystitis. Common symptoms include
frequency, dysuria, urgency, suprapubic pain, cloudy
urine, hematuria, nausea, vomiting, and fever. A history
is the most important tool for the diagnosis of acute
uncomplicated cystitis, and it should be supported by a
focused examination and urinalysis.
Option B: Acute pyelonephritis may be suspected if the
patient is ill-appearing and seems uncomfortable,
particularly if she has a concomitant fever, tachycardia,
or costovertebral angle tenderness.
Option C: Pyelonephritis may have similar symptoms of
cystitis but usually will have flank pain, fever, and other
systemic symptoms. Acute pyelonephritis is a bacterial
infection causing inflammation of the kidneys.
Pyelonephritis occurs as a complication of an ascending
urinary tract infection that spreads from the bladder to
the kidneys.
Option D: Costovertebral tenderness, flank pain, and
high fever are signs and symptoms of pyelonephritis, an
upper UTI. Acute pyelonephritis will classically present
as a triad of fever, flank pain, and nausea or vomiting,
but not all symptoms have to be present. Symptoms will
usually develop within several hours or over the course
of a day.
22. When educating parents regarding known
antecedent infections in acute glomerulonephritis, which
of the following should the nurse cover?
A. Scabies
B. Impetigo
C. Herpes simplex
D. Varicella
Impetigo, a bacterial infection of the skin, may be
caused by streptococci and may precede acute
glomerulonephritis. Although most streptococcal
infections do not cause acute glomerulonephritis, when
they do, a latent period of 10 to 14 days occurs between
the infection, usually of the skin (impetigo) or upper
respiratory tract, and the onset of clinical manifestations.
Option A: Scabies is not associated with acute
glomerulonephritis. Scabies is a contagious skin
condition resulting from the infestation of a mite. The
Sarcoptes scabiei mite burrows within the skin and
causes severe itching. This itch is relentless, especially
at night. Skin-to-skin contact transmits the infectious
organism therefore, family members and skin contact
relationships create the highest risk.
Option C: Herpes simplex is not associated with acute
glomerulonephritis. Risk factors for HSV-1 infection
differ depending on the type of HSV-1 infection. In the
case of orolabial herpes, risk factors include any activity
that exposes one to an infected patient’s saliva, for
example, shared drinkware or cosmetics, or mouth-to-
mouth contact.
Option D: Varicella is not associated with acute
glomerulonephritis. Chickenpox or varicella is a
contagious disease caused by the varicella-zoster virus
(VZV). The virus is responsible for chickenpox (usually
primary infection in non-immune hosts) and herpes
zoster or shingles (following reactivation of latent
infection).
23. Which of the following organisms is the most
common cause of urinary tract infection (UTI) in
children?
A. Klebsiella
B. Staphylococcus
C. Escherichia coli
D. Pseudomonas
E. coli is the most common organism associated with
the development of UTI. Escherichia coli is the most
common organism in uncomplicated UTI by a large
margin. Pathogenic bacteria ascend from the perineum,
causing the UTI. Women have shorter urethras than
men and therefore are far more susceptible to UTI. Very
few uncomplicated UTIs are caused by blood-borne
bacteria.
Option A: E.coli causes the vast majority of UTIs but
other organisms of importance include proteus,
klebsiella, and enterococcus. The diagnosis of UTI is
made from the clinical history (symptoms) and urinalysis
with confirmation by a urine culture, but the proper
collection of the urine sample is important.
Option B: Staphylococcus aureus is a major bacterial
human pathogen that causes a wide variety of clinical
manifestations. Infections are common both in
community-acquired as well as hospital-acquired
settings and treatment remains challenging to manage
due to the emergence of multi-drug resistant strains
such as MRSA (Methicillin-Resistant Staphylococcus
aureus).
Option D: Although Klebsiella, Staphylococcus, and
Pseudomonas species may cause UTIs, the incidence
of UTIs related to each is less than that for E. coli.
Pseudomonas aeruginosa is commonly found in the
environment, particularly in freshwater. It is commonly
an opportunistic pathogen and is also an important
cause of nosocomial infections like ventilator-associated
pneumonia, catheter-associated urinary tract infections,
and others.
24. Which of the following should be included when
developing a teaching plan to prevent urinary tract
infection? Select all that apply.
A. Maintaining adequate fluid intake
B. Avoiding urination before and after intercourse
C. Emptying bladder with urination
D. Wearing underwear made of synthetic material such
as nylon
E. Keeping urine alkaline by avoiding acidic beverages
F. Avoiding bubble baths and tight clothing
Even with proper antibiotic treatment, most UTI
symptoms can last several days. In women with
recurrent UTIs, the quality of life is poor. About 25% of
women experience such recurrences. Many cases of
uncomplicated UTIs will resolve spontaneously, without
treatment, but many patients seek therapy for symptom
relief.
Option A: Fluid intake helps dilute urine and minimize
infection potential. Even without treatment, most UTIs
will spontaneously resolve in about 20% of women;
especially if increased hydration is used. The likelihood
that a healthy female will develop acute pyelonephritis is
very small.
Option B: Void before and after intercourse (if sexually
active). Sexual intercourse is a common cause of a UTI
as it promotes the migration of bacteria into the bladder.
Although there is no proof of prevention, women should
urinate after sexual intercourse because bacteria in the
bladder can increase by ten-fold after intercourse.
Option C: Emptying the bladder fully with each urination
prevents stasis. People who frequently void and empty
the bladder tend to have a lower risk of a UTI. Frequent
urination and high urinary volumes are also known to
decrease the risk of UTI.
Option D: Children and teens should wear cotton
underwear. The majority of organisms causing a UTI are
enteric coliforms that typically inhabit the periurethral
vaginal introitus. These organisms ascend the urethra
into the bladder and cause UTI.
Option E: Keep the urine acidic. Urine is an ideal
medium for bacterial growth. Factors that make it less
favorable for bacterial growth include a pH less than 5,
the presence of organic acids, and high levels of urea.
Normal urine pH is slightly acidic, with usual values of
6.0 to 7.5, but the normal range is 4.5 to 8.0. A urine pH
of 8.5 or 9.0 is often indicative of a urea-splitting
organism, such as Proteus, Klebsiella, or Ureaplasma
urealyticum.
Option F: Bubble baths and tight clothing may act as
irritants. Vigorous urine flow is helpful to prevention.
Baths should be avoided in favor of showers. A gentle,
liquid soap should be used in bathing (such as Ivory or
Dial) or a liquid baby soap such as Johnson’s baby
shampoo which is very acceptable for the vagina.
25. Nurse Jeremy is evaluating a client’s fluid intake and
output record. Fluid intake and urine output should relate
in which way?
A. Fluid intake should double the urine output.
B. Fluid intake should be approximately equal to the
urine output.
C. Fluid intake should be half the urine output.
D. Fluid intake should be inversely proportional to the
urine output.
Normally, fluid intake is approximately equal to the urine
output. Any other relationship signals an abnormality.
One general principle for all patient scenarios is to
replace whatever fluid is being lost as accurately as
possible. The strategy of managing a patient’s fluid
differs depending on each patient’s clinical condition. If
they can drink adequate fluid volumes by mouth, this
should be the first choice. Some patients can tolerate
other enteral options, such as feeding tubes. IV plus oral
orders are effective for those unable to meet their total
daily fluid requirements enterally.
Option A: Fluid intake that is double the urine output
indicates fluid retention. Monitor for peripheral edema,
pulmonary edema, or hepatomegaly. It is important to
consider underlying cardiac dysfunction or renal failure
and adjust volumes of administration accordingly. These
patients might require a lower maintenance fluid rate
than expected for their body weight.
Option C: Fluid intake that is half the urine output
indicates dehydration. A drop of at least 20 mm Hg
systolic blood pressure or 10 mm Hg diastolic blood
pressure within 2 to 5 minutes of quiet standing after 5
minutes of supine rest indicates orthostatic hypotension.
Dehydrated or elderly patients who have lost sensitivity
in their baroreceptors in their blood vessels might
display these findings.
Option D: Normally, fluid intake isn’t inversely
proportional to the urine output. One can see weight
gain in states of fluid excess and weight loss in states of
fluid deficit. It is also helpful to look at patient records to
see any recent outpatient visits before hospitalization,
which might indicate a patient’s normal baseline weight.
26. A child diagnosed with intellectual disability (ID) is
under the supervision of Nurse Tasha. The nurse is
aware that the signs and symptoms of mild ID include
which of the following?
A. Few communication skills
B. Lateness in walking
C. Mental age of a toddler
D. Noticeable developmental delays
Mild intellectual disability is minimally noticeable in
young children, with one of the signs being a delay in
achieving developmental milestones, such as walking at
a later stage. Individuals with an intellectual disability
have neurodevelopmental deficits characterized by
limitations in intellectual functioning and adaptive
behavior. These disabilities originate and manifest
before the age of 18 and can be associated with a
considerable number of related and co-occurring
problems.
Option A: Severe intellectual disability is marked by
little or no communication skills. Intellectual functioning
is generally called intelligence and includes a wide
range of mental activities such as the ability of logical
reasoning and practical intelligence (problem-solving),
ability in learning, verbal skills, and so on.
Option C: Severe intellectual disability is marked by the
mental age of a toddler. Concerning clinical history,
symptoms of intellectual disability usually begin during
childhood or adolescence. Moreover, delays in language
or motor skills may be observed by age two.
Nevertheless, a significant number of children with mild
levels of intellectual disability may not get identified until
school age.
Option D: Children with moderate intellectual disability
have noticeable developmental delays. All skills are
learned throughout development and performed in
response to common problems and simple/complex
tasks as well as expectations from our community and
society. Obviously, these behavioral responses become
progressively more complex with age.
27. Nurse Kathy is assessing infantile reflexes in a 9-
month-old baby; which of the following would she
identify as normal?
A. Persistent rooting
B. Bilateral parachute
C. Absent moro reflex
D. Unilateral grasp
The parachute reflex appears to be normal at about 9
months of age. Persistence of primitive reflexes past 4
to 6 months or absence before this time when they
should have been present is predictive of cerebral palsy.
The presence of 5 or more abnormal reflexes correlated
with the development of cerebral palsy or mental delays.
Option A: The rooting reflex, mouth turning toward an
object, is seen in response to light stroking on the cheek
or bringing an object into the patient’s visual field.
Rooting begins at 32 weeks gestation and decreases
after one month.
Option C: The absence of the Moro reflex suggests
CNS dysfunction. The Moro reflex is a protective
response to the abrupt disruption of body balance and is
elicited by pulling up on the arms with an infant in the
supine position. The reflex develops by 28 weeks
gestation and disappears by six to nine months.
Option D: The grasping reflex can be elicited by
providing sustained pressure on the palmar aspect of
the hand, resulting in flexion of the patient’s fingers
grasping the object providing the pressure. This reflex
develops by 28 weeks gestation and disappears by six
months.
28. The American Association on Mental Deficiency
(AAMD), now American Association on Intellectual and
Developmental Disabilities (AAIDD) definition of mental
retardation emphasizes which of the following?
A. An IQ level that must be below 50
B. Cognitive impairment occurring after age 22 years
C. Deficits in adaptive behavior with intellectual
impairment
D. No responsiveness to contact
Mental retardation is part of a broad category of
developmental disability and is defined by the American
Association of Mental Deficiency as “significantly
subaverage, general intellectual functioning existing
concurrently with deficits in adaptive behavior and
manifested during the developmental period (18 years of
age).”
Option A: IQ of 70 or below is considered significantly
subaverage intellectual functioning. One way to
measure intellectual functioning is an IQ test. Generally,
an IQ test score of around 70 or as high as 75 indicates
a limitation in intellectual functioning.
Option B: Cognitive impairment isn’t part of the
definition. However, the definition does state that the
impairment or compromise must occur before age 22
years old. This condition is one of several
developmental disabilities—that is, there is evidence of
the disability during the developmental period, which is
defined as before the age of 22.
Option D: But in defining and assessing intellectual
disability, the AAIDD stresses that additional factors
must be taken into accounts, such as the community
environment typical of the individual’s peers and culture.
Professionals should also consider linguistic diversity
and cultural differences in the way people communicate,
move, and behave.
29. After explaining to the parents about their child’s
unique psychological needs related to a seizure disorder
and possible stressors, which of the following interests
uttered by them would indicate further teaching?
A. Feeling different from peers
B. Poor self-image
C. Cognitive delays
D. Dependency
Children with seizure disorders do not necessarily have
cognitive delays. Epilepsy is one of the most serious
neurological conditions and has an impact not only on
the affected individual but also on the family and,
indirectly, on the community. A global approach to the
individual must take into account cognitive problems,
psychiatric comorbidities and all psychosocial
complications that often accompany epilepsy.
Option A: Others have found that children feel that
having epilepsy is stigmatizing and keep their condition
a secret from their friends (MacLeod and Austin, 2003).
Epilepsy is a condition still highly stigmatized, and
stigma greatly affects the QoL of people with epilepsy,
leading to increased anxiety and depression and poor
adherence to medication.
Option B: In focus groups with children with epilepsy,
McNelis and colleagues (2007) found that children were
afraid to talk to their parents because they did not want
to worry them. Social support mechanisms help people
to overcome many of the difficulties they encounter.
Individuals with good social support usually have an
increased sense of control over their lives, enabling
them to have better coping mechanisms for handling
adversities.
Option D: Dependency can put additional stress on a
child trying to understand and manage chronic illness.
Austin and colleagues (1993) found that children
reflected their parents’ fears including those related to
procedures, dying, and becoming mentally ill.
Successful integration of people with epilepsy into
society is another important goal in epilepsy care.
30. Olivia is an adolescent who has seizure disorder;
which of the following would not be a focus of a teaching
program?
A. Ability to obtain a driver's license
B. Drug and alcohol abuse
C. Increased risk of infections
D. Peer pressure
Adolescents with seizure disorders are at no greater risk
for infections than other adolescents. Adolescence is the
period during which the child’s identity as an individual in
his/her own right should be consolidated. Achieving
independence from parents, establishing healthy
interpersonal relationships outside the family and
choosing a vocation are essential developmental tasks
of adolescence.
Option A: The ability to get a driver’s license may be
determined by the adolescent’s seizure history. As the
age for driving approaches, it is often worthwhile to
review the adolescent’s medical care. If no seizures
have occurred for several years, it may be wise to
attempt to lower and eventually stop medications at
least 6 months or a year before the driving age is
reached.
Option B: Drug and alcohol use may conflict with or
cause adverse reactions from anticonvulsants. The rules
concerning alcohol use and epilepsy apply to both teens
and adults, but greater caution applies to the younger
group. Drinking one or two alcoholic beverages causes
no meaningful changes in the blood levels of
antiepileptic drugs or in seizure control.
Option D: Peer pressure may put the child at risk for
increased risk-taking behaviors that may intensify
seizure activity. The developmental tasks of middle
childhood include becoming more independent of
parents and more attached to peers. During this stage, it
is crucial for the child’s psychosocial development to be
actively involved in peer groups and to achieve success
in the school environment.
31. The 6-year-old son of Mr. and Mrs. Peters is
admitted to the healthcare facility with the diagnosis of
idiopathic hypopituitarism. His height is measured below
the third percentile and weight at the 40th percentile.
Which of the following would be the first action of his
attending nurse?
A. Recommend orthodontic referral for underdeveloped
jaw.
B. Collaborate with a dietician to access his caloric
needs.
C. Provide for a tutor for his precocious intellectual
ability.
D. Place him in a room with a 2-year-old boy.
Because the child’s weight is excessive for his height,
he needs a dietary assessment and a weight-loss
program. Weight gain typically is out of proportion to
growth, resulting in relative obesity. This obesity is
truncal in distribution; skull and head circumference
growth are typically preserved, producing the impression
of a large head.
Option A: An underdeveloped jaw is not usually a
problem with hypopituitarism. Common presenting
features include growth failure, disorders of pubertal
development, and diabetes insipidus. Growth failure
may be the most common presenting symptom in this
age group, possibly with an associated delay in tooth
development.
Option C: Providing a tutor to educate him is an
appropriate action, but the rationale is incorrect.
Although children with hypopituitarism generally appear
intellectually precocious because of the disparity
between their size and their cognitive ability, they are
usually of normal intelligence.
Option D: Placing the child in a room with a toddler
could contribute to poor self-esteem. Depending on the
etiology of hypopituitarism, associated findings in the
neonate, infant, or child may include developmental
delay, various visual and neurologic symptoms, seizure
disorder, and a number of congenital malformation
syndromes.
32. While Lawrence is being assessed at the clinic,
Nurse Rachel observed that the child appears to be
small, with an immature face and chubby body build.
Her parents stated that their child’s rate of growth of all
body parts is somewhat slow, but her proportions and
intelligence remain normal. As a knowledgeable nurse,
you know that the child has a deficiency of which of the
following?
A. Antidiuretic hormone (ADH)
B. Parathyroid hormone (PTH)
C. Growth hormone (GH)
D. Melanocyte-stimulating hormone (MSH)
GH stimulates protein anabolism, promoting bone and
soft-tissue growth. A lack of GH would lead to
decreased synthesis of somatomedin, resulting in
decreased linear growth and decreased fat metabolism,
and increased glucose uptake in muscles, resulting in
excessive subcutaneous fat hypoglycemia.
Option A: A deficiency in ADH results in diabetes
insipidus, marked by dehydration and hypernatremia.
Diabetes insipidus (DI) is a disease process that results
in either decreased release of antidiuretic hormone
(ADH, also known as vasopressin or AVP) or decreased
response to ADH, causing electrolyte imbalances.
Option B: Deficiency of PTH causes hypocalcemia,
marked by tetany, convulsions, and muscle spasms. It’s
not uncommon after thyroid or other head and neck
surgeries to get transient or permanent
hypoparathyroidism leading to hypocalcemia. This can
be a result of unintentional removal of parathyroid
glands or a loss of blood supply in some cases.
Option D: Deficiency of MSH causes diminished or
absent skin pigmentation. Melanocyte-stimulating
hormone (alpha-melanotropin, MSH) may function in a
number of diverse physiological roles. MSH stimulates
(1) rapid translocation of melanosomes (melanin
granules) in dermal melanophores to effect rapid color
change and (2) melanogenesis in normal and abnormal
(melanoma) epidermal melanocytes.
33. In growing children, growth hormone deficiency
results in short stature and very slow growth rates. Short
stature may result from which of the following?
A. Anterior pituitary gland hypofunction
B. Posterior pituitary gland hyperfunction
C. Parathyroid gland hyperfunction
D. Thyroid gland hyperfunction
Short stature usually results from diminished or deficient
growth hormone, which is released from the anterior
pituitary gland. Growth hormone production from the
anterior pituitary is regulated by the stimulatory and
inhibitory control of the hypothalamus. Hypothalamus
produces growth hormone-releasing hormone that
stimulates the somatotrophs of the anterior pituitary to
secrete growth hormone.
Option B: Posterior pituitary hyperfunction results in
increased secretion of antidiuretic hormone or oxytocin,
leading to a syndrome of inappropriate antidiuretic
hormone secretion, marked by fluid retention and
hyponatremia. SIADH is excess ADH production from
the posterior pituitary or an ectopic source. Elevated
levels result in excess water retention and hypervolemic
hyponatremia.
Option C: Parathyroid hypofunction leads to
hypocalcemia. Parathyroid hormone deficiency, also
called hypoparathyroidism, results in hypocalcemia,
hyperphosphatemia, and increased neuromuscular
irritability. Patients may present with myalgias, muscle
spasms, and in extreme cases tetany.
Option D: Thyroid hyperfunction causes increased
secretion of thyroxine, triiodothyronine, and
thyrocalcitonin, resulting in Graves’ disease, marked by
accelerated linear growth and early epiphyseal closure.
34. Mr. Lopez has a 7-year-old son with growth hormone
(GH) deficiency. He shares to the nurse the desire of his
son to play ball games. However, his wife feels the child
will be in danger since he is smaller than the other
children. In planning anticipatory guidance for these
parents, the nurse should keep in mind which of the
following?
A. The child should be allowed to play because
doing so can foster healthy self-esteem.
B. The risk for fractures is increased because a GH
deficiency results in fragile bones.
C. Activity could aggravate insulin sensitivity, causing
hyperglycemia.
D. Activity would aggravate the child's joints, already
over tasked by obesity.
Engaging in peer-group activities can aid foster a sense
of belonging and a positive self-concept. T-ball is a good
sport to choose because physical stature is not an
important consideration in the ability to participate,
unlike some other sports, such as basketball and
football. Physical examination may not reveal any
significant findings as the presentation is usually subtle.
Option B: Hypopituitarism does not affect calcium and
phosphorus homeostasis and demineralization of bone.
So the risk for fractures is not increased. Clinical
features of hypopituitarism may be subtle and ill-defined
or severe with the acute presentation. Presenting signs
and symptoms may be linked to those of a deficiency of
the pituitary hormone, mass effects in the presence of
pituitary tumors, and/or features of the causative
disease.
Option C: Although rare, physical activity without
adequate carbohydrate intake can cause hypoglycemia.
GH and/or cortisol deficiency more commonly cause
hypoglycemia, which results from decreased
gluconeogenesis and increased glucose utilization
(owing to increased tissue sensitivity to insulin in the
absence of GH and cortisol).
Option D: Moderate physical activity increases caloric
use and reduces weight without undue strain on weight-
bearing joints. Reduced aerobic capacity is a prominent
manifestation among patients with GH deficiency (GHD).
Exercise training may improve the physiological capacity
to undertake an aerobic activity.
35. A child newly diagnosed with diabetes mellitus has
been stabilized with insulin injections daily. A nurse
prepares a discharge teaching plan regarding the
insulin. The teaching plan should reinforce which of the
following concepts?
A. Always keep insulin vials refrigerated
B. Increase the amount of insulin before exercise
C. Ketones in the urine signify a need for less insulin
D. Systematically rotate injection sites
It is necessary to rotate injection sites because injecting
in the same place much of the time can cause hard
lumps or extra fat deposits to develop. Insulin delivery is
by multiple daily injections (MDI) or an insulin pump to
simulate endogenous insulin physiology. Multiple daily
injections include basal insulin once or twice daily, and
bolus insulin typically is given at meals three or more
times daily and is based on carbohydrate content and
current blood glucose.
Option A: All insulins are sensitive to temperatures that
are too high or too low. Store all the supplies received in
the refrigerator. Once a vial is opened, keep it stored in
the fridge or at room temperature. Be aware that
injecting refrigerated insulin may be painful. Inspect your
insulin before each use. Look for changes in color or
clarity. Look for clumps, solid white particles, or crystals
in the bottle or pen. Insulin that is clear should always be
clear and never look cloudy.
Option B: Daily exercise for 60 mins is recommended;
check blood glucose before and after exercise to detect
hypoglycemia and hyperglycemia. An exercise specialist
should teach the child what exercises may be beneficial.
Option C: Monitor for ketones when the child is ill or has
an infection. Insufficient insulin and/or poor oral intake
may lead to the development of ketosis. If not
recognized and treated appropriately, ketoacid
increases and causes acidosis which if severe may
require hospitalization.
36. Mr. and Mrs. Andrews’ child was diagnosed with
Duchenne’s muscular dystrophy; which of the following
usually is the first indication of the condition?
A. Inability to suck in the newborn
B. Lateness in walking in the toddler
C. Difficulty running in the preschooler
D. Decreasing coordination in the school-age child
Usually, signs and symptoms of Duchenne’s muscular
dystrophy are not noticed until ages 3 to 5 years.
Typically weakness starts with the pelvic girdle,
evidenced as difficulty running in the preschooler.
Duchenne’s muscular dystrophy usually is not
diagnosed in the infant or toddler period.
Option A: Sucking is not the first sign of Duchenne’s
muscular dystrophy. In ambulatory patients, an
increased incidence of fractures is noted as a
consequence of the frequent falls. Enlargement of the
calves with wasting of the thigh muscles results in
pseudohypertrophy of the calves, which is a classical
feature. Aside from the calves, hypertrophy of the
tongue and muscles of the forearm may be seen but are
less classical.
Option B: Signs and symptoms of muscular dystrophy
are not noticed until ages 3 to 5 years. Weakness and
difficulty in ambulation is typically first noted between 2
and three years of life. This manifests as toe walking,
difficulty running, climbing up stairs, and frequently
falling.
Option D: Mild hypotonia in an infant may be present,
and poor head control in an infant may be an initial sign.
Patients do not have atypical facies, but with the onset
of facial muscle weakness, a transverse or horizontal
sign may be seen in later childhood. Weakness is more
pronounced in proximal than distal muscles and the
lower limb more than the upper limb.
37. Which of the following is the most common
permanent disability in childhood?
A. Scoliosis
B. Muscular dystrophy
C. Cerebral palsy
D. Developmental dysplasia of the hip (DDH)
Cerebral palsy is the most common permanent disability
of childhood. It is a group of disabilities caused by injury
or insult to the brain either before or during birth, or in
early infancy. A cerebral palsy is a group of permanent
disorders affecting the development of movement and
causing a limitation of activity. Non-progressive
disturbances that manifest in the developing fetal or
infant brain lead to cerebral palsy.
Option A: Scoliosis should not cause permanent
disability. The prognosis of the deformity is related
heavily to the skeletal maturity of the patient as well as
the degree of deformity. Thoracic to sacral spine grows
at approximately 2 cm per year for the first 5 years of life
and then 1 cm per year from ages 5 to 10 with 1.8 cm
per year until maturity.
Option B: Muscular dystrophy is a group of disorders
that cause progressive degeneration and weakness of
skeletal muscles. The prevalence of muscular dystrophy
among the general population is 16 to 25.1 per 100,000.
The most common childhood muscular dystrophy is
Duchenne muscular dystrophy.
Option D: The long-term outcome of treated DDH is
based on the degree of dysplasia, the age of diagnosis
and type of treatment, and whether a concentrically
reduced hip joint was obtained. If left untreated over a
prolonged period, there will be a gradual progression of
functional disability and causes accelerated
osteoarthritis.
38. When a child injures the epiphyseal plate from a
fracture, the damage may result in which of the
following?
A. Rheumatoid arthritis
B. Permanent nerve damage
C. Osteomyelitis
D. Bone growth disruption
The epiphyseal plate is a significant region of bone
growth. Hence, any disruption may result in limb
shortening. Sometimes, changes in the growth plate
from the fracture can cause problems later. For
example, the bone could end up a little crooked or a bit
longer or shorter than expected.
Option A: Rheumatoid arthritis is a collagen disease
with an autoimmune component, with no relationship to
fractures. The etiology of RA remains unknown. It is
thought to result from the interaction between patients’
genotype and environment. Cigarette smoking is the
strongest environmental risk factor associated with
rheumatoid arthritis.
Option B: Nerve damage may occur with any fracture,
but growth disruption is a primary concern at the
epiphyseal plate. Nerves travel in close proximity to the
bones and joints. A fracture or dislocation could thus
potentially damage a nerve, in addition to the bony
injury. As the fracture or dislocation itself is a painful and
distressing injury, the presence of a nerve injury may not
be recognized immediately.
Option C: Osteomyelitis may occur with any fracture,
but growth disruption is a primary concern at the
epiphyseal plate. Osteomyelitis is a serious infection of
the bone that can be either acute or chronic. It is an
inflammatory process involving the bone and its
structures caused by pyogenic organisms that spread
through the bloodstream, fractures, or surgery.
39. Mrs. Cooper is concerned about her 4-month-old
son’s unusual condition; which of the following
statements made by her would indicate that the child
may have cerebral palsy?
A. "He holds his left leg so stiff that I have a hard time
putting on his diapers."
B. "My baby won't lift his head up and look at me;
he's so floppy."
C. "My baby's left hip tilts when I pull him to standing
position."
D. "I'm very worried because my baby has not rolled all
the way over yet."
Hypotonia or floppy infant is an early manifestation of
cerebral palsy. Typically, the infant lifts his head to a 90-
degree angle by age 4 months with only a partial head
lag by age 2 months. Clinical signs and symptoms of
cerebral palsy can include micro- or macrocephaly,
excessive irritability or diminished interaction, hyper- or
hypotonia, spasticity, dystonia, muscle weakness, the
persistence of primitive reflexes, abnormal or absent
postural reflexes, incoordination, and hyperreflexia.
Option A: Although rigidity and tenseness are possible
signs of cerebral palsy, a limitation in one leg suggests
DDH. The physical exam should focus on identifying
clinical signs of cerebral palsy. Head circumference,
mental status, muscle tone and strength, posture,
reflexes (primitive, postural, and deep tendon reflexes),
and gait should undergo evaluation.
Option C: Tilting of the hip is an indication of
developmental dysplasia of the hip (DDH). Clinical
features vary for mild hip instability, limited abduction in
the infant, asymmetric gait in the toddler, hip pain in
adolescence, and osteoarthritis in the adult.
Option D: Rolling completely over usually does not
occur until the infant is 6 months. Though many 4-
month-olds get pretty adept at rolling over, by 6 months
old, most infants have mastered not only the stomach-
to-back roll but also the reverse back-to-stomach
maneuver.
40. Scott is a teenager suffering from osteomyelitis; the
nurse would expect which of the following symptoms?
Select all that apply.
A. Fever
B. Irritability
C. Pallor
D. Tenderness
E. Swelling
The symptoms for acute and chronic osteomyelitis are
very similar and include fever, irritability, fatigue,
nausea, tenderness, redness (not pallor in option C),
and warmth in the area of the infection, swelling around
the affected bone, and lost range of motion.
Option A: There may be a dull pain with or without
motion and sometimes constitutional symptoms such as
fever or chills. In subacute presentations, some patients
may have generalized malaise, mild pain over several
weeks with minimal fever, or other constitutional
symptoms.
Option B: Physical examination should focus primarily
on finding a possible nidus of infection, assessing
sensory function, and peripheral vasculature. Some
patients are at high risk for osteomyelitis, and these
include those with bacteremia, endocarditis, intravenous
drug use, trauma, and open fractures.
Option C: In chronic osteomyelitis, symptoms may
occur over a longer duration of time, usually more than
two weeks. As with acute osteomyelitis, patients may
also present with swelling, pain, and erythema at the site
of infection, but constitutional symptoms like fever are
less common.
Option D: Tenderness to palpation over vertebral bone
may be a significant finding in vertebral osteomyelitis.
The ability to probe an ulcer to the bone with a blunt
sterile instrument is highly suggestive of osteomyelitis.
Option E: Acute osteomyelitis may present gradually
with onset over a few days but usually manifests within
two weeks. Patients may have local symptoms such as
erythema, swelling, and warmth at the site of infection.
41. Nurse Emma is planning a client education program
for sickle cell disease (SCD); What topic should be
included in the plan of care?
A. Aerobic exercise to improve oxygenation
B. Fluid restraint to 1 qt (1 L)/day
C. A high-iron, high-protein diet
D. Proper hand washing and infection avoidance
Prevention of infection is vital in the prevention of sickle
cell crisis. Patients with SCD are especially at risk for
infections with encapsulated organisms because of their
functional asplenia, as well as because of functionally
immunocompromised state (increased bone marrow
turnover and altered complement activation).
Option A: Strenuous activities and exercises should be
withdrawn to lessen the risk of increased tissue
ischemia. Because acute intense exercise may alter
these pathophysiological mechanisms, physical activity
is usually contraindicated in patients with SCD.
Option B: Proper hydration should be encouraged to
prevent crises secondary to dehydration. Erythrocytes
are more likely to sickle and become rigid in the
presence of dehydration. This process is in large part
caused by changes in cation homeostasis, specifically
increased potassium and water efflux mediated by
potassium-chloride cotransport and Gardos channels
(calcium-dependent potassium channel).
Option C: A high-iron, high-protein diet would have no
impact on the disease or prevention of a crisis. Patients
with sickle cell anemia have greater than average
requirements for both calories and micronutrients and
therefore need to eat more to avoid being deficient in
immune-boosting nutrients.
42. In children diagnosed with sickle cell disease (SCD),
tissue damage results from which of the following?
A. Air hunger and respiratory alkalosis due to
deoxygenated red blood cells.
B. Hypersensitivity of the central nervous system (CNS)
due to elevated serum bilirubin levels
C. A general inflammatory response due to an
autoimmune reaction from hypoxia
D. Local tissue damage with ischemia and necrosis
due to obstructed circulation
Characteristic sickle cells tend to clump, which results in
weak and inadequate blood flow to the tissue, local
tissue damage, and eventual ischemia and necrosis.
There is increased adhesion of erythrocytes followed by
the formation of heterocellular aggregates, which
physically cause small vessel occlusion and resultant
local hypoxia.
Option A: Air hunger and respiratory alkalosis are not
present. The most common symptoms in patients with
ACS are fever, cough, chest pain, dyspnea, and lung
exam may show reduced air entry, rales, and sometimes
wheeze. ACS can progress rapidly to hypoxemia and
respiratory failure if not treated promptly.
Option B: The CNS effects result from ischemia.
Management of sickle cell complications is tailored to
the type of complication. VOC management consists of
rapid pain assessment, early initiation of analgesic
therapy, and maintaining this analgesia (consider PCA
pump) and hydration until there is symptom relief.
Option C: In sickle cell anemia, the damage is not due
to inflammation response. Microvascular occlusion (the
cardinal pathophysiologic cause of acute pain) leads to
ischemia and hypoxia, followed by tissue and vascular
damage and inflammation, the release of inflammatory
mediators, all of which activate nociceptors.
43. Which of the following tests is most effective in
diagnosing hemophilia?
A. Bleeding time
B. Complete blood count (CBC)
C. Partial thromboplastin time (PTT)
D. Platelet count
PTT is abnormal in hemophilia. Therefore, this test will
be the most helpful in diagnosing the disorder. In both
hemophilia A and B, PTT will be prolonged (intrinsic
pathway disruption), whereas PT and BT will be normal.
The PTT could be as prolonged as 2 to 3 times the high
normal range. Once PTT is found to be prolonged, it
should be followed by a mixing study.
Option A: Bleeding time is normal in hemophilia.
Kaneshiro in 1969 confirmed that the mean bleeding
time was normal in hemophilia. However, 2 of 11
patients with severe hemophilia A had prolonged
baseline bleeding times of 12 and 15 min, respectively.
Option B: The CBC is not affected in hemophilia. After
the prenatal period, the initial laboratory work includes
but is not limited to complete blood count, prothrombin
time (PT), partial thromboplastin time (PTT), and
bleeding time (BT).
Option D: The severity of the disease correlates with
remaining factor levels, although individual differences in
bleeding tendency are seen despite similar factor levels.
While thrombin generation is severely impaired in
persons with hemophilia, primary hemostasis, i.e.
platelet function has been generally considered to be
normal.
44. A child with thalassemia was given deferoxamine
(Desferal); which of the following should alert the nurse
to notify the physician?
A. Decreased hearing
B. Hypertension
C. Red urine
D. Vomiting
Deferoxamine is ototoxic. Thus, any hearing problem
should be immediately addressed to the physician.
Chronic deferoxamine therapy can lead to sensorineural
hearing loss and retinopathy. Hearing and vision loss
can be reversible if the patient discontinues DFO early in
the course. A screening hearing exam should be
performed in the clinic every six months and a formal
audiogram every 12 months.
Option B: Hypotension, not hypertension, is a possible
adverse effect. Complication risk can be mitigated while
using DFO by keeping the therapeutic index below
0.025, and the patient’s daily dose requires adjustment
for the alternating ferritin levels. Besides monitoring the
patient’s iron stores, it is also advisable to regularly
screen for adverse effects.
Option C: Red urine is an expected occurrence with
deferoxamine. Chelation of iron and formation of the
water-soluble compound ferioxamine may lead to vine
rose-colored urine. Since the kidneys excrete most of
the chelation byproduct ferrioxamine, it is essential to
monitor the patient’s renal function.
Option D: Vomiting is not an emergency with this drug.
Acute side effects can include GI complaints,
anaphylaxis, skin discoloration, skin irritation, and
anaphylaxis. Administering less than 2.5 g of DFO per
day and monitoring the therapeutic index is the best way
to avoid such complications.
45. Mr. and Mrs. Robertson’s son was diagnosed with
idiopathic thrombocytopenic purpura. They should be
aware that the drug to be avoided is:
A. Acetaminophen
B. Aspirin
C. Codeine
D. Morphine
Aspirin exerts an antiplatelet action and therefore may
increase platelet destruction in ITP. Aspirin inhibits
platelet function by acetylating platelet cyclooxygenase,
increasing the risk of bleeding because it adds a
prolonged platelet functional defect to the quantitative
defect already present from the severe
thrombocytopenia.
Option A: Acetaminophen (paracetamol) is widely used
for postoperative analgesia. Its mechanism of action is
inhibition of prostaglandin synthesis in the central
nervous system, and acetaminophen is traditionally not
considered to influence platelet function.
Option C: Non-steroidal anti-inflammatory drugs
(NSAID), such as ibuprofen (Nurofen, etc.) should also
be avoided for similar reasons. Paracetamol or codeine
can be recommended for adults.
Option D: Although it has a very low incidence
worldwide, morphine-induced thrombocytopenia can
occur in some patients especially with higher doses.
From eHealthMe study, from the FDA reports published
On January 26, 2015: There were 48,666 people
reported to have side effects when taking morphine.
Among them, 156 people (0.32%) have Heparin-induced
Thrombocytopenia.
46. A nurse provides medication instructions to a first-
time mother. Which statement made by the mother
indicates a need for further instructions?
A. "I should mix the medication in the baby food
and give it when I feed the child".
B. "I should administer the oral medication sitting in an
upright position and with the head elevated".
C. "I will give my child a toy after giving the medication".
D. "I will offer my child a juice drink after swallowing the
medication".
The nurse would teach the mother to avoid putting
medications in foods because it may cause an
unpleasant taste to the food, and the child may refuse to
accept the same food in the future. Additionally, the child
may not consume the entire serving and would not
require medication dosage.
Option B: Administering the medication in an upright
position and head elevation will prevent the risk of
aspiration. Do not squirt medicine directly at the back of
the baby’s throat. This may cause the child to choke.
Option C: Offering a toy will provide comfort measures
to the child. Praise the child every time he takes the
medicine without a struggle. (Giving a special sticker
works well for some children.)
Option D: The mother should offer drinks such as juice
or a soft drink to lessen the aftertaste of the medication.
Some medicines can be put in a small amount of juice or
sugar water. Follow the instructions from the doctor,
nurse, or pharmacist. Do not put medicine in a full bottle
or cup in case the infant does not drink very much.
47. A physician prescribes an IV solution of 500 ml
0.45% Saline with an incorporation of 20mEq potassium
chloride for a child with dehydration. The nurse should
check which of the following before administering this IV
prescription?
A. Blood pressure
B. Height
C. Weight
D. Urine output
When it comes to hypotonic dehydration, electrolyte loss
exceeds water loss. The priority assessment for the
nurse is to check the urinary output before the
administration. Potassium chloride is contraindicated for
patients with oliguria or anuria. The body becomes
dehydrated when it loses more fluids than it consumes.
When the body doesn’t have enough fluids, it can’t
process potassium properly, and potassium builds up in
the blood, which can lead to hyperkalemia.
Option A: Many randomized trials have shown that
potassium chloride supplementation lowers blood
pressure. However, potassium in fruits and vegetables is
not a chloride salt, but a mixture of potassium
phosphate, sulfate, citrate, and many organic anions
including proteins.
Option B: A substantial decrease in potassium occurs
over the 20-80 age range (33 % for males and 39 % for
females), suggesting that two processes, dilution of
body K concentration by added fat and reduction in
muscle mass, are both occurring. Standard gives
greater emphasis to height than to weight.
Option C: There is some evidence from cross-sectional
studies that potassium intake may be negatively linked
to obesity. In three different reports from Korea and
Japan, there appeared to be a trend for the lower
prevalence of obesity or the MS with higher
consumption of potassium.
48. An infant with a patent ductus arteriosus is admitted
to the pediatric unit ward. The nurse anticipates which of
the following medications will be given to the infant?
A. Prednisone
B. Ibuprofen
C. Penicillin
D. Albuterol
When surgical ligation is not indicated, prostaglandin
inhibitors (e.g. nonsteroidal anti-inflammatory drugs
[NSAIDs]) are used to close the ductus arteriosus. In
April 2006, the US Food and Drug Administration
approved the use of ibuprofen lysine (NeoProfen) for the
closure of clinically significant PDA in premature
neonates. Ibuprofen’s mechanism of action for closure
of PDA is believed to be through the inhibition of
prostaglandins.
Option A: Prednisone is an FDA-approved, delayed-
release corticosteroid indicated as an anti-inflammatory
or immunosuppressive agent to treat a broad range of
diseases, including immunosuppressive/endocrine,
rheumatic, collagen, dermatologic, allergic states,
ophthalmic, respiratory, hematologic, neoplastic,
edematous, gastrointestinal, acute exacerbations of
multiple sclerosis, and as an anti-inflammatory and an
antineoplastic agent.
Option C: Penicillin is one of the most commonly used
antibiotics globally, as it has a wide range of clinical
indications. Penicillin is effective against many different
types of infections involving gram-positive cocci, gram-
positive rods (e.g., Listeria), most anaerobes, and gram-
negative cocci (e.g., Neisseria).
Option D: Albuterol is used for the treatment and
prevention of bronchospasm (acute or severe) in
patients with reversible obstructive airway disease. It
also has an indication for the prevention of exercise-
induced bronchospasm.
49. A child with Kawasaki disease is admitted to the
pediatric ward. Which of the following medications will
you expect to be a part of the treatment? Select all that
apply.
A. Gamma Globulin
B. Warfarin.
C. Acetaminophen
D. Aspirin
E. Atenolol
The principal goal of treatment for Kawasaki disease is
to prevent coronary artery disease and to relieve
symptoms such as fever and joint pain so an antipyretic,
antiplatelet, and gamma globulin is used. Treatment
aims with Kawasaki disease point to minimize the risk of
coronary artery aneurysm (CAA) formation, which peaks
two to four weeks after illness onset, by decreasing the
inflammation of the coronary arteries. Supportive care is
also essential.
Option A: Patients should receive high dose IVIG at 2
g/kg over 10-12 hours as well as high dose aspirin
(ASA) (80 mg/kg/day to 100 mg/kg/day divided every six
hours) until the patient has been afebrile for over 48
hours. Ideally, IVIG should be started within 7-10 days of
the onset of fever to prevent potential cardiac
complications and can decrease CAA formation from
25% to 3-5%.
Option B: Low-molecular-weight-heparin or warfarin
(with a goal of INR 2 to 2.5) is recommended in patients
who have large CAAs, as well as an antiplatelet agent
(clopidogrel or dipyridamole) to prevent thrombus
formation due to decreased flow and the damaged
epithelium.
Option C: This is antipyretic but is not responsive to this
disease. Acetaminophen (APAP) is a non-opioid
analgesic and antipyretic agent used to treat pain and
fever. It is used as a single agent for mild to moderate
pain and in combination with an opioid analgesic for
severe pain.
Option D: ASA is believed to modulate platelet activity
by downregulating inflammation and preventing
thrombosis; however, there is no evidence to support
that ASA actually prevents the development of CAA. It is
also of note that children are at higher risk of developing
Reye syndrome if they develop influenza or varicella
infections while taking ASA, and children should receive
the influenza vaccine and abstain from the varicella
vaccine while taking ASA.
Option E: This is a beta-blocker. Atenolol is a second-
generation beta-1-selective adrenergic antagonist
indicated in the treatment of hypertension, angina
pectoris, and acute myocardial infarction.

50. A 6-year-old child is scheduled to have measles,

mumps, and rubella (MMR) vaccine. Which of the
following routes will you expect the nurse to administer
the vaccine?

A. Intramuscularly in the vastus lateralis muscle.

B. Intramuscularly in the deltoid muscle.
C. Subcutaneously in the gluteal area.
D. Subcutaneously in the outer aspect of the upper
arm.

(MMR) the vaccine is administered subcutaneously in

the outer aspect of the upper arm. The dosage for both
MMR and MMRV is 0.5 mL. Both vaccines are
administered by the subcutaneous route.

Option A: The preferred injection site in small children

is the anterolateral aspect of the thigh. The posterior
triceps aspect of the upper arm is the preferred site for
older children and adolescents.
Option B: MMR is not administered intramuscularly.
The preferred injection site for adults is the posterior
triceps aspect of the upper arm. If a second dose is
indicated, the minimum interval between the first and
second doses should be separated by at least 4 weeks
(28 days).
Option C: Gluteal area is not used as a site. The
minimum age for both MMR and MMRV is 12 months of
age. The typical age for the second dose of either
vaccine is at 4 to 6 years of age. The maximum age for
the administration of MMRV is 12 years. It should not be
administered to anyone 13 years of age or older.