Pediatric Nursing NCLEX Challenge Exam:
Part 2
1. Nurse Elizabeth is administering medication via the
intraosseous route to a child. Intraosseous drug
administration is typically used when a child is:
A. Under age 3
B. Over age 3
C. Critically ill and under age 3
D. Critically ill and over age 3
In an emergency, intraosseous drug administration is
typically used when a child is critically ill and under age
3. IO access provides a means of administering
medications, glucose, and fluids, as well as (potentially)
a means of obtaining blood samples. Such a situation
would include any resuscitation; cardiopulmonary arrest;
shock, regardless of etiology; life-threatening status
epilepticus; or lack of venous access resulting from
burns, edema, or obesity.
Option A: In the 1980s, IO access was rediscovered as
an immediately available tool in resuscitation situations,
when time is of the essence and conditions may be
adverse. Since then, IO access has become widely
accepted in pediatric settings, especially because these
patients often provide a particular challenge to obtaining
rapid intravascular access.
Option B: Initiation of IO access is indicated in adults,
children, infants, or newborns in any clinical situation
where vascular access is emergently needed but not
immediately available via a peripheral vein.
Option D: A retrospective study by Carlson et al found
that in 2011, among out-of-hospital critical procedures
provided for pediatric patients by emergency medical
services in the United States, IO access was one of the
most common.
2. When administering an I.M. injection to an infant, the
nurse in charge should use which site?
A. Deltoid
B. Dorsogluteal
C. Ventrogluteal
D. Vastus lateralis
The recommended injection site for an infant is the
vastus lateralis or rectus femoris muscles. Skeletal
muscle can accommodate larger volumes of medication
than subcutaneous tissue, and absorption is faster
because muscle tissue is highly vascular. Muscle has
fewer pain-sensing nerves than subcutaneous tissue
and is less sensitive to irritating and viscous
medications, so pain is lessened.
Option A: The deltoid is inappropriate. The deltoid in
infants is not sufficiently bulky to absorb IM medications
adequately. The vastus lateralis muscle avoids the
thicker layer of subcutaneous fat on the anterior thigh.
Option B: Using the vastus lateralis muscle avoids the
risk of sciatic nerve damage from gluteal injection. Also,
the vastus lateralis muscle has a larger muscle mass
than the gluteal region and therefore has reduced risk of
severe local reactions.
Option C: The ventrogluteal site can be used only in
toddlers who have been walking for about 1 year.
Although recent literature has reported that the
ventrogluteal area can be an alternative site for
intramuscular injections in children ?12 months of age,
little research-based evidence has been found for the
use of the ventrogluteal site in infants and toddlers.
3. Nurse Charlotte suspects that a child, age 4, is being
neglected physically. To best assess the child’s
nutritional status, the nurse should ask the parents
which question?
A. “Has your child always been so thin?”
B. “Is your child a picky eater?”
C. “What did your child eat for breakfast?”
D. “Do you think your child eats enough?”
The nurse should obtain objective information about the
child’s nutritional intake, such as by asking about what
the child ate for a specific meal. In order to assess the
adequacy of a child’s nutritional intake, dietitians require
detailed information about all food and drink consumed.
As all children admitted to the hospital are at risk of
nutritional deficit, a dietary record should be started on
all in-patients, although this may subsequently be
discontinued when deemed appropriate.
Option A: Children should be weighed on admission to
the hospital and subsequently at least once a week. The
frequency of weighing requires adjustment according to
clinical conditions in discussion with the multidisciplinary
team. Repeat weights should be recorded under similar
conditions and at the same time of day as the original
measurement.
Option B: The dietary record should include details of
food and fluids offered and consumed, with quantities
expressed in terms of teaspoons, tablespoons, and so
on. Owing to the difficulties of providing for the likes and
dislikes of individual children any record of dietary intake
completed during admission is unlikely to provide an
ideal reflection of a child’s customary intake.
Option D: A nursing assessment interview conducted
on admission should elicit useful information pertaining
to feeding history and parental concerns regarding
feeding and growth/weight gain.
4. During a well-baby visit, Liza asks the nurse when
she should start giving her infant solid foods. The nurse
should instruct her to introduce which solid food first?
A. Applesauce
B. Egg whites
C. Rice cereal
D. Yogurt
Rice cereal is the first solid food an infant should receive
because it is easy to digest and is associated with few
allergies. Next, the infant can receive pureed fruits, such
as bananas, applesauce, and pears, followed by pureed
vegetables, egg yolks, cheese, yogurt, and finally, meat.
Option A: Delicious, digestible first fruits include finely
mashed bananas, baby applesauce, peaches, and
pears. For something completely different, and
completely baby-friendly, start with smoothed-down
mashed or pureed ripe avocado — it’s creamy, yummy,
and loaded with healthy fats.
Option B: Egg whites should not be given until age 9
months because they may trigger a food allergy.
Potentially allergenic foods include cow’s milk products,
eggs, fish, shellfish, tree nuts, peanuts, wheat, soy, and
sesame. Introduce potentially allergenic foods when
other foods are introduced.
Option D: Drinking cow’s milk or fortified soy beverages
is not recommended until your child is older than 12
months, but other cow’s milk products, such as yogurt,
can be introduced before 12 months.
5. When performing a physical examination on an infant,
the nurse in charge notes abnormally low-set ears. This
finding is associated with:
A. Otogenous tetanus
B. Tracheoesophageal fistula
C. Congenital heart defects
D. Renal anomalies
Normally the top of the ear aligns with an imaginary line
drawn across the inner and outer canthus of the eye.
Ears set below this line are associated with renal
anomalies or mental retardation. This is due to the
observation that auricular malformations often are
associated with specific MCA syndromes that have high
incidences of renal anomalies.
Option A: Otogenic tetanus is a subtype of cephalic
tetanus, usually limited to the muscles and nerves of the
head and neck, but can also progress to a more
generalized form. It usually is the result of tetanus
spores gaining entry into the middle ear of otitis media
through a tympanic membrane perforation.
Option B: TEF is most commonly associated with other
congenital anomalies, particularly cardiac defects.
Esophageal atresia (EA) is a related congenital
malformation with a similar presentation to TEF and can
occur with or without the presence of a fistula.
Option C: Low-set ears do not have congenital heart
defects. Many cases of CHD are multifactorial and result
from a combination of genetic predisposition and
environmental risk factors. CCHD is usually isolated and
sporadic, but it can also be associated with genetic
syndromes. Approximately 15% to 20% of infants with
CCHD are related to known chromosomal abnormalities,
most of these are aneuploidies (trisomy 21, 13, and 18
and Turner syndrome).
6. The nurse is evaluating a female child with acute post
streptococcal glomerulonephritis for signs of
improvement. Which finding typically is the earliest sign
of improvement?
A. Increased urine output
B. Increased appetite
C. Increased energy level
D. Decreased diarrhea
Increased urine output, a sign of improving kidney
function, typically is the first sign that a child with acute
post-streptococcal glomerulonephritis (APSGN) is
improving. PSGN typically presents with features of the
nephritic syndrome such as hematuria, oliguria,
hypertension, and edema, though it can also present
with significant proteinuria.
Option B: Increased appetite is not specific to APSGN.
Poststreptococcal glomerulonephritis (PSGN) results
from a bacterial infection that causes rapid deterioration
of the kidney function due to an inflammatory response
following streptococcal infection.
Option C: An increased energy level is not specific to
APSGN. When symptomatic, PSGN typically presents
with features of the nephritic syndrome such as
hematuria, oliguria, hypertension, and edema. Less
common presentations can mimic nephrotic syndrome
with significant proteinuria.
Option D: Decreased diarrhea is not specific to APSGN.
The most common presenting symptom is gross
hematuria as it occurs in 30 to 50% of cases with acute
PSGN; patients often describe their urine as smoky, tea-
colored, cola-colored, or rusty.
7. How should the nurse prepare a suspension before
administration?
A. By diluting it with normal saline solution
B. By diluting it with 5% dextrose solution
C. By shaking it so that all the drug particles are
dispersed uniformly
D. By crushing remaining particles with a mortar and
pestle
The nurse should shake a suspension before
administration to dispersed drug particles uniformly.
First, the bottle should be tabbed a few times to loosen
the powder, then approximately, half the volume of
water should be added, the bottle is shaken vigorously,
the remaining water should be added and shaken well.
Option A: In one study 75.5 % of mothers used boiled
then cooled tap water and 1.8 % of mothers used
distilled water, which is a correct practice. The addition
of water in one step makes it difficult to get the lumps
out while measuring the volume of water several times
increases the percentage of error in measured volume.
Option B: Only tap water should be reconstituted with a
powdered suspension because a 5% dextrose solution
contains chemicals that may cause decomposition of
drugs and complex reactions.
Option D: Crushing particles is not recommended for
this drug form. Crushing or opening modified or slow-
release drug capsules will cause the drug to be released
all at once and could cause side effects. There may be
times when tablets will need to be crushed in order to
deliver essential drug therapy. This should only be done
as a last resort and the practitioner must use her or his
professional judgment.
8. Mandy, age 12, is brought to the clinic for evaluation
for a suspected eating disorder. To best assess the
effects of role and relationship patterns on the child’s
nutritional intake, the nurse should ask:
A. “What activities do you engage in during the day?”
B. “Do you have any allergies to foods?”
C. “Do you like yourself physically?”
D. “What kinds of food do you like to eat?”
Role and relationship patterns focus on body image and
the patient’s relationship with others, which are
commonly interrelated with food intake. Eating behaviors
evolve during the first years of life; children learn what,
when, and how much to eat through direct experiences
with food and by observing the eating behaviors of
others.
Option A: Parents influence children’s eating behavior
in a variety of ways: parents actively make food choices
for the family, serve as models for dietary choices and
patterns, and use feeding practices to reinforce the
development of eating patterns and behaviors that they
deem appropriate.
Option B: Questions about food allergies elicit
information about health and illness patterns. Parents
who are concerned about their child’s diet may attempt
to limit what and how much food is eaten, pressure their
child to eat a healthier diet or reward their child for
eating healthy foods, practices which may all lead to
unintended consequences.
Option C: Questions about activities and food
preferences elicit information about health promotion
and health protection behaviors. Children also learn
about food by observing the eating behaviors modeled
by others. For example, research reveals that children’s
intake of fruits, vegetables, and milk increased after
observing adults consuming the foods.
9. A child is diagnosed with Wilms’ tumor. During
assessment, the nurse in charge expects to detect:
A. Gross hematuria
B. Dysuria
C. Nausea and vomiting
D. An abdominal mass
The most common sign of Wilms’ tumor is a painless,
palpable abdominal mass, sometimes accompanied by
an increase in abdominal girth. Wilms tumor usually
presents as an asymptomatic abdominal mass in the
majority of children. The mother may have discovered
the mass during bathing the infant.
Option A: Gross hematuria is uncommon, although
microscopic hematuria may be present. Abdominal pain
is the most common initial presenting symptom (30% to
40%), followed by hypertension (25%) and hematuria
(12% to 25%).
Option B: Dysuria is not associated with Wilms’ tumor.
Wilms tumor, or nephroblastoma, is the most common
renal cancer in the pediatric age group. It is also the
most common pediatric abdominal cancer and the fourth
most common pediatric cancer overall.
Option C: Nausea and vomiting are rare in children with
Wilms’ tumor. The cause of Wilms tumor is not precisely
known, but it is believed to be due to genetic alterations
that deal with the normal embryological development of
the genitourinary tract.
10. Which of the following organisms is responsible for
the development of rheumatic fever?
A. Streptococcal pneumonia
B. Haemophilus influenza
C. Group A beta-hemolytic streptococcus
D. Staphylococcus aureus
Rheumatic fever results from a delayed reaction to
inadequately treated group A ?-hemolytic streptococcal
infection. In order for ARF to occur, it appears that a
pharyngeal infection caused by S. pyogenes must occur
in a host with a genetic susceptibility to the disease.
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.
Option A: Streptococcus pneumoniae is a gram-
positive, lancet-shaped bacterium and a cause of
community-acquired pneumonia. Pneumococcal
infections are present throughout the world and are most
prevalent during the winter and early spring months.
Streptococcus pneumoniae is the bacterium that has
historically been the most common pathogen to cause
CAP worldwide.
Option B: Haemophilus influenzae disease is a name
collectively used for any kind of infection caused by the
bacteria called Haemophilus influenzae. The most
familiar and predominant form is H. influenzae type b
(Hib), which infects mostly children and
immunocompromised individuals.
Option D: 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).
11. Nurse Nancy is assessing a child with pyloric
stenosis; she is likely to note which of the following?
A. "Currant jelly" stools
B. Regurgitation
C. Steatorrhea
D. Projectile vomiting
Projectile vomiting is a key sign of pyloric stenosis.
Pyloric stenosis, also known as infantile hypertrophic
pyloric stenosis (IHPS), is an uncommon condition in
infants characterized by abnormal thickening of the
pylorus muscles in the stomach leading to gastric outlet
obstruction. Clinically infants are well at birth. Then, at 3
to 6 weeks of age, the infants present with “projectile”
vomiting, potentially leading to dehydration and weight
loss.
Option A: “Currant jelly” stools are characteristic of
intussusception. 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. Later signs include rectal
bleeding, often with “red currant jelly” stool, and
lethargy. Physical examination may reveal a “sausage-
shaped” mass.
Option B: Regurgitation is seen more commonly with
gastroesophageal reflux. Gastroesophageal reflux
disease (GERD) is a condition that develops when there
is a retrograde flow of stomach contents back into the
esophagus. It can present as a non-erosive reflux
disease or erosive esophagitis.
Option C: Steatorrhea occurs in malabsorption
disorders such as celiac disease. Steatorrhea is one of
the clinical features of fat malabsorption and is noted in
many conditions such as exocrine pancreatic
insufficiency (EPI), celiac disease, and tropical sprue.
An increase in the fat content of stools results in the
production of pale, large volume, malodorous, loose
stools.
12. Baby Jonathan was born with cleft lip (CL); Nurse
Barbara would be alert that which of the following will
most likely be compromised?
A. GI function
B. Locomotion
C. Sucking ability
D. Respiratory status
Because of the defect, the child will be unable to form a
mouth adequately around the nipple, thereby requiring
special devices to allow for feeding and sucking
gratification. Patients with cleft lips inherently will have
some degree of alveolar cleft with potential for collapse
of the maxillary arch and class III malocclusion (the
maxillary teeth sit posterior to the mandibular teeth).
These hard and soft tissue anatomic changes translate
to the various changes in appearance, speech, and
swallowing/feeding seen in cleft lip patients.
Option A: GI functioning is not compromised in the child
with a CL. Speech-language therapists and nutrition
consults are usually required to teach parents
techniques to meet the special feeding needs of these
children. When patients do not meet feeding
requirements for adequate nutrition, which is most
common when there is a concomitant cleft palate,
feeding access is sometimes required with the
assistance of the pediatric surgery team.
Option B: Locomotion would be a problem for older
infants because of the use of restraints. Nurses who
look after these infants should be fully aware of the risk
of aspiration, airway obstruction, and difficulties with
feeding. There is no single method of feeding that works
in all children and the mother should be educated on the
different techniques to help the infant latch on the nipple.
In general, the recommendation is a soft nipple that may
need to be angled.
Option D: Respiratory status may be compromised if
the child is fed improperly during the postoperative
period. The mother should be taught about the potential
for aspiration and choking. If the infant fails to gain
weight, a visit to the pediatrician is highly recommended.
13. Which of the following parameters would Nurse Max
monitor to evaluate the effectiveness of thickened
feedings for an infant with gastroesophageal reflux
(GER)?
A. Urine
B. Vomiting
C. Weight
D. Stools
Thickened feedings are used with GER to stop the
vomiting. Therefore, the nurse would monitor the child’s
vomiting to evaluate the effectiveness of using the
thickened feedings. The feeding management strategy
has been shown to represent an effective approach in
otherwise healthy infants with both GER and GERD. It
involves modifying feeding frequency and volume,
ensuring the intake of feed per kilogram of weight is
appropriate. There is some evidence for the efficacy of
feed thickeners on reducing visible regurgitation
Option A: No relationship exists between feedings and
urine. Patients with GER and GERD may also benefit
from changing body position, by keeping them upright or
even in the prone position, especially in the postprandial
period.
Option C: If feedings are ineffective, this should be
noted before there is any change in the child’s weight.
Identify the amount of weight loss needed for optimal
body size and frame. Provides a basis for dietary
planning.
Option D: If the first-line management fails to improve
symptoms, current pediatric guidelines advise for a 2–4
weeks trial with cow’s milk protein-free diet, by either
excluding milk from the maternal diet in breastfed infants
or by using hydrolyzed formula in non-breast fed infants.
14. Nurse Karen is providing postoperative care for
Dustin who had a cleft palate (CP) repair; the nurse
should position the child in which of the following?
A. In an infant seat
B. In the supine position
C. In the prone position
D. On his side
Postoperatively, children with a cleft palate should be
placed on their abdomens to facilitate drainage. A child
who has had a cleft lip repair should be positioned on
their side or back to keep them from rubbing their face in
the bed. A child with only a cleft palate repair may sleep
on their stomach. It is important to keep the stitches
clean and without crusting.
Option A: Using an infant seat does not facilitate
drainage. It is important to keep the child from hurting
the incision or putting hands or toys in their mouth. For
this reason, they will wear arm restraints (e.g., NoNo’s)
which keep them from bending their elbows. These are
also used for 10 days after surgery.
Option B: If the child is placed in the supine position,
aspiration is a concern. There may be some discomfort
as the child swallows so they may not drink much the
first evening. This is why IV fluids are continued until
their drinking improves. Pain medicine will also be given
to relieve distress.
Option D: Side-lying does not facilitate drainage as well
as the prone position. The goal after surgery is to protect
the new repair and stitches. For this reason, there will be
some changes in the child’s feeding, positioning, and
activity for a short time.

15. Mrs. Johnson tells the nurse that she is very worried
because her 2-year old child does not finish his meals.
What should the nurse advise the mother?
A. Make the child seat with the family in the dining room
until he finishes his meal
B. Provide quiet environment for the child before meals
C. Do not give snacks to the child before meals
D. Put the child on a chair and feed him
If the child is hungry he/she is more likely to finish his
meals. Therefore, the mother should be advised not to
give snacks to the child. Set times for meals and snacks
and try to stick to them. A child who skips a meal finds it
reassuring to know when to expect the next one. Avoid
offering snacks or pacifying hungry kids with cups of
milk or juice right before a meal — this can diminish their
appetite and decrease their willingness to try a new food
being offered.
Option A: The child is a “busy toddler.” He/she will not
be able to keep still for a long time. For some kids,
dinner becomes a negotiation session from the very
start, and parents have been using dessert as an
incentive for decades. But this doesn’t encourage
healthy eating. Instead, it creates the impression that
“treats” are more valuable than mealtime food.
Option B: Be alert to what toddlers say through their
actions. A child who is building a tower of crackers or
dropping carrots on the floor may be telling you he or
she is full. Pushing food on a child who’s not hungry
may dull the internal cues that help kids know when
they’ve eaten enough. Kids can manage their hunger
when they come to expect that food will be available
during certain times of the day. If a child chooses not to
eat anything at all, simply offer food again at the next
meal or snack time.
Option D: Kids should start finger feeding around 9
months of age and try using utensils by 15-18 months.
Some parents think that not letting kids feed themselves
is for the best, but it takes away control that rightfully
belongs to kids at this age. They need to decide whether
to eat, what they will eat, and how much to eat — this is
how they learn to recognize the internal cues that tell
them when they’re hungry and when they’re full. Just as
important, toddlers need to learn and practice the
mechanics of feeding themselves.
16. Niklaus was born with hypospadias; which of the
following should be avoided when a child has such
condition?
A. Surgery
B. Circumcision
C. Intravenous pyelography (IVP)
D. Catheterization
Hypospadias refers to a condition in which the urethral
opening is located below the glans penis or anywhere
along the ventral surface (underside) of the penile shaft.
The ventral foreskin is lacking, and the distal portion
gives an appearance of a hood. Early recognition is
important so that circumcision is avoided; the foreskin is
used for surgical repair.
Option A: Surgery is the procedure of choice to improve
the child’s ability to stand when urinating, improve the
appearance of the penis, and preserve sexual
adequacy. Patients diagnosed with hypospadias should
be referred for surgical evaluation within the first weeks
of life. If parents want circumcisions for their newborns,
the presence of any penile abnormality should
contraindicate the procedure, given that the foreskin is
used in arthroplasties.
Option C: IVP is contraindicated if the child has an
allergy to iodine or shellfish. Intravenous pyelography
(IVP), or intravenous urography, is a diagnostic test that
involves the administration of intravenous contrast and
X-ray imaging of the urinary tract.
Option D: Catheterization may be used to ensure
urinary elimination. Hypospadias is the most frequent
anatomical variant of the penis and occurs during
development when hormonal triggers malfunction and
the urethra does not properly tubularize. The urethral
meatus can be found anywhere along the glans, penile
shaft, scrotum, or perineum, leading to a difficult
catheterization.
17. Stephen was diagnosed with minimal-change
nephrotic syndrome; which of the following signs and
symptoms are characteristics of the said disorder?
A. Hypertension, edema, hematuria
B. Hypertension, edema, proteinuria
C. Gross hematuria, fever, proteinuria
D. Poor appetite, edema, proteinuria
Clinical manifestations of nephrotic syndrome include
loss of appetite due to edema of the intestinal mucosa,
proteinuria, and edema. The classic NS presentation is
edema, in the early phase is located in the face in the
morning on waking with puffiness of the eyelids and the
impression of the folds of sheets on the skin and ankles
at the end of the day.
Option A: Proteinuria that is more than 85% albumin is
selective proteinuria. Albumin has a net negative
charge, and it is proposed that loss of glomerular
membrane negative charges could be important in
causing albuminuria.
Option B: Hypertension alone or accompanied by
hematuria is associated with glomerulonephritis.
Moderate arterial hypertension is present in 25% of
cases, and hypotension may reveal a state of effective
hypovolemia.
Option C: Gross hematuria is not associated with
nephrotic syndrome. Fever will occur only if infection
also exists. Functional renal failure is possible.
Microscopic hematuria is noted in about 20% of cases,
macroscopic hematuria being exceptional and having to
make look for thrombosis of the renal veins.
18. Patient S is a sexually active adolescent. Which of
the following instructions would be included in the
preventive teaching plan about urinary tract infections?
A. Drinking acidic juices
B. Avoiding urinating before intercourse
C. Wearing nylon underwear
D. Wiping back to front
Drinking acidic juices, such as cranberry juice, helps
keep the urine at its desired pH and reduces the chance
of infection. Pure cranberry juice, cranberry extract, or
cranberry supplements may help prevent repeated UTIs
in women, but the benefit is small. It helps about as
much as taking antibiotics to prevent another UTI.
Option B: Many health authorities, including the
Centers for Disease Control and Prevention (CDC),
recommend urinating after sex to prevent UTIs. Doing
so may help flush away bacteria that are close to the
urethra and prevent them from entering the urinary tract.
Option C: Synthetic fabrics trap moisture and create the
perfect breeding ground for infection. If the patient is
prone to UTIs, she should wear loose-fitting bottoms that
allow air to circulate around the vagina. At night, the
patient can wear loose-fitting boxers or shorts.
Option D: After urinating, tilt the body forward and,
reaching between the buttocks, start wiping from the
front of the vagina to the back. Doing so prevents the
introduction of bacteria from the anus to the vagina.
19. 12-year-old Caroline has recurring nephrotic
syndrome. Which of the following areas of potential
disturbances should be a prime consideration when
planning ongoing nursing care?
A. Body image
B. Sexual maturation
C. Muscle coordination
D. Intellectual development
Because of edema associated with nephrotic syndrome,
potential self-concept, and body image disturbances
related to changes in appearance and social isolation
should be considered. Nephrotic syndrome is a
condition that causes the kidneys to leak large amounts
of protein into the urine. This can lead to a range of
problems, including swelling of body tissues and a
greater chance of catching infections.
Option B: Sexual maturation is not affected. Instruct
parents to provide frequent oral hygiene. Oral hygiene
reduces dryness of the mouth and mucous membranes.
Advise them to limit fluid intake as ordered. The amount
of allowed fluid intake is determined based on the child’s
weight, urine output, and response to treatment.
Option C: Muscle coordination is not affected. Assess
their knowledge of disease, signs and symptoms of
relapse, dietary and activity aspects of care, medication
administration and side effects, monitoring urine and
vital signs. This provides information about education
needs for follow-up care.
Option D: Intellectual function is not affected. Offer
parents and child with praise and encouragement as
they acquire skills. Positive reinforcement improves
willingness to learn new skills.
20. The following are considered functions of the Urinary
System, EXCEPT:
A. Vitamin D synthesis
B. Regulation of red blood cell synthesis
C. Excretion
D. Absorption of digested molecules
E. Regulation of blood volume and pressure
This is a function of the digestive system. The small
molecules that result from digestion are absorbed
through the walls of the intestine for use in the body.
Digestion is the process of mechanically and
enzymatically breaking down food into substances for
absorption into the bloodstream.
Option A: This is a function of the urinary system. The
kidneys play an important role in controlling blood levels
of Ca2+ by regulating the synthesis of vitamin D. The
kidneys have an important role in making vitamin D
useful to the body. The kidneys convert vitamin D from
supplements or the sun to the active form of vitamin D
that is needed by the body. With chronic kidney disease,
low vitamin D levels can be found, sometimes even
severely low levels.
Option B: This is a function of the urinary system. The
kidneys secrete a hormone, erythropoietin, which
regulates the synthesis of red blood cells in the bone
marrow. The kidney produces 85 percent of circulating
erythropoietin; the liver, the remainder. If you move to a
higher altitude, the partial pressure of oxygen is lower,
meaning there is less pressure to push oxygen across
the alveolar membrane and into the red blood cell.
Option C: This is a function of the urinary system. The
kidneys are the major excretory organs of the body.
They remove waste products, many of which are toxic,
from the blood. The urinary system includes the kidneys,
ureters, bladder and urethra. This system filters the
blood, removing waste and excess water. This waste
becomes urine.
Option E: This is a function of the urinary system. The
kidneys play a major role in controlling the extracellular
fluid volume in the body by producing either a large
volume of dilute urine or a small volume of concentrated
urine. Due to osmosis, water follows where Na+ leads.
Much of the water the kidneys recover from the forming
urine follows the reabsorption of Na+. Antidiuretic
hormone stimulation of aquaporin channels allows for
regulation of water recovery in the collecting ducts. It is
through these means that blood volume and osmolarity
are regulated by the kidneys.
21. Nurse Nancy is teaching Mr. and Mrs. Diaz about
the early signs and symptoms of lead poisoning. Which
of the following if stated by the couple would indicate the
need for further understanding of the case?
A. Anemia
B. Seizures
C. Irritability
D. Anorexia
Seizures usually are associated with encephalopathy, a
late sign of lead poisoning. Typically, lead levels have
already exceeded 70 mg/dl. In the appropriate clinical
setting, lead encephalopathy should be considered in
patients presenting with delirium, altered mental status,
or seizures. As lead encephalopathy often presents with
altered sensorium, obtaining a history directly from the
patient can be challenging.
Option A: Key features of the patient’s history that
should raise the index of suspicion for lead
encephalopathy may include associated abdominal pain,
constipation, or anemia, which are other common
findings of lead intoxication.
Option C: Particularly in sub-acute cases, additional
history of preceding ataxia, headache, sensory or motor
deficits, agitation, or irritability may be present. Finally,
obtaining a detailed environmental history is important in
understanding the route and magnitude of potential lead
intoxication.
Option D: A physical exam will primarily reveal CNS
derangement. Generally speaking, patients afflicted with
lead encephalopathy will appear to be globally altered.
They may also exhibit signs of peripheral neuropathy on
the exam, such as wrist drop and loss of 2 point
discrimination.
22. Reye’s syndrome is a rare and severe illness
affecting children and teenagers. Its development has
been linked with the use of aspirin and which of the
following?
A. Meningitis
B. Encephalitis
C. Strep throat
D. Varicella
Reye’s syndrome has been linked with the ingestion of
aspirin in children with viral infections like varicella.
Epidemiologic studies found a link between the use of
salicylate and the development of Reye syndrome.
While less than 0.1% of children who took aspirin
developed Reye syndrome, more than 80% of children
diagnosed with Reye syndrome had taken aspirin in the
preceding 3 weeks.
Option A: Reye syndrome is most commonly
precipitated by viral pathogens such as influenza A and
B as well as varicella. Center for Disease Control and
Prevention (CDC) surveillance data between 1980 and
1997 found that cases of Reye syndrome were
preceded by influenza infection 73%, varicella infection
21%, and gastroenteritis infections 14% of the time.
Option B: Encephalitis is a component of Reye’s
syndrome. Features such as lack of viral prodrome,
family history of IEM, a family history of unexplained
encephalopathy, preexisting neurologic symptoms, and
patient age less than one year make the diagnosis of
Reye syndrome less likely.
Option C: There is no association between bacterial
infections such as strep throat and the development of
Reye’s syndrome. Serum salicylate concentrations were
detectable in 82% of cases. Less commonly associated
viral associations are seen with coxsackie,
parainfluenza, Epstein-Barr (EBV), cytomegalovirus
(CMV), adenovirus, and hepatitis. Bacterial pathogens
such as Chlamydia, Bordetella pertussis, Mycoplasma,
and Shigella have also been associated with the
development of Reye syndrome.
23. Nurse Dorothy is caring for a child with Category A
Near Drowning; she should do which of the following?
Select all that apply.
A. Give furosemide as ordered.
B. Check for increased intracranial pressure
C. Plan for discharge in 12 to 24 hours.
D. Check for electrolyte imbalances.
E. Keep mechanical ventilation.
F. Provide oxygen as ordered.
Near-drowning is defined as survival for at least 24
hours from suffocation by submersion. Aspiration of
water causes the plasma to be pulled into the lungs,
resulting in hypoxemia, acidosis, and hypovolemia.
Hypoxemia results from the decrease in pulmonary
surfactant caused by the absorbed water that leads to
damage of the pulmonary capillary membrane. Children
with Category A Near Drowning are awake with minimal
injury. Care includes checking electrolyte status,
administering oxygen and warming, and preparing for
discharge in 12 to 24 hours.
Option A: Administer sodium bicarbonate as ordered.
Metabolic acidosis is corrected by the administration of
sodium bicarbonate. Administer fluid volume expanders
as ordered. Volume expanders are the intravenous fluid
solutions that are used to increase or retain the volume
of fluid in the circulating blood. It can also correct fluid
imbalances.
Option B: Assess the client’s level of consciousness.
Within three minutes of submersion, near-drowning
clients are unconscious and are at risk for cerebral
edema.
Option C: Patient disposition depends on the history,
presence of associated injuries, and degree of
immersion injury. Patients can be safely discharged from
the ED after 6-8 hours of observation if they meet the
criteria.
Option D: Monitor client’s laboratory values, as ordered:
hematocrit (this assessment determines the level of
hemodilution or concentration.), sodium (serum sodium
levels decline with hemodilution), potassium
(hypokalemia may result from the increase in urinary
output), and blood pH (Acidosis and alkalosis require
correction).
Option E: Administer hyperventilation, as ordered in
collaboration with the respiratory therapist.
Hyperventilation blows off carbon dioxide to control
cerebral blood flow and, in turn, controls the increase in
ICP. This reduces the risk of seizures.
Option F: Maintain oxygenation levels. Adequate
oxygenation prevents further hypoxic damage. Monitor
oxygen saturation and ABGs as ordered. Oxygen
saturation should be at 90% or greater. Decreasing
PaO2 and pulse oximetry readings and increasing
PaCo2 are signs of respiratory failure.
24. Spina bifida is one of the possible neural tube
defects that can occur during early embryological
development. Which of the following definitions most
accurately describes meningocele?
 A. Complete exposure of spinal cord and meninges
B. Herniation of the spinal cord and meninges into a sac
C. Sac formation containing meninges and spinal
fluid
D. Spinal cord tumor containing nerve roots
Meningocele is a sac formation containing meninges
and cerebrospinal fluid (CSF). Meningocele is the
simplest form of open neural tube defects characterized
by cystic dilatation of meninges containing cerebrospinal
fluid without any neural tissue. A complex meningocele
is associated with other spinal anomalies. Meningocele
is a typically asymptomatic spinal anomaly and is not
associated with acute neurologic conditions.
Option A: Meningocele doesn’t involve complete
exposure of the spinal cord and meninges; this is a
massive defect that’s incompatible with life. A simple
meningocele composed of meninges and CSF protruded
into the subcutaneous tissue through a spinal defect.
Skin overlying meningoceles are usually intact.
Option B: Myelomeningocele is a herniation of the
spinal cord, meninges, and CSF into a sac that
protrudes through a defect in the vertebral arch.
Myelomeningocele is the most common open neural
tube defect. It is characterized by failure of the neural
tube to close in the lumbosacral region during embryonic
development (fourth-week post-fertilization), leading to
the herniation of the meninges and spinal cord through a
vertebral defect.
Option D: Tumor formation is not associated with this
defect. Meningocele presents as a swelling over the
back covered with skin, present at birth. Defects can
present at thoracolumbar, lumbosacral, lumbar, thoracic,
sacral, and cervical regions. Neurological involvement
and deficits are rare in meningocele.
25. Benjamin was rushed to the emergency department
with possible increased intracranial pressure (ICP);
which of the following is an early clinical manifestation of
increased ICP in older children?
A. Macewen's sign
B. Setting sun sign
C. Papilledema
D. Diplopia
Diplopia is an early sign of increased ICP in an older
child. Visual changes can range from blurred vision,
double vision from cranial nerve defects, photophobia to
optic disc edema and eventually optic atrophy. Clinical
suspicion for intracranial hypertension should be raised
if a patient presents with the following signs and
symptoms: headaches, vomiting, and altered mental
status varying from drowsiness to coma.
Option A: Macewen sign refers to a “cracked pot”
sound that is noted on percussion of the head. “The
cracked pot sound,” Macewen’s sign, was originally
described by Macewen in his book, Pyogenic infectious
diseases of the brain and spinal cord in 1893. The
method of elicitation of differential cranial percussion as
an aid to cerebral diagnosis was practiced by him for
years, particularly in children.
Option B: The setting sun appearance of the eyes is
noted in infants with increased ICP. The sunset eye sign
(also known as the setting sun phenomenon) is a clinical
phenomenon encountered in infants and young children
with raised intracranial pressure (seen in up to 40% of
children with obstructive hydrocephalus and 13% of
children with shunt dysfunction).
Option C: Papilledema is a late sign of increased ICP. If
the raised ICP is not treated, this can lead to optic
atrophy and vision loss. The absence of papilledema
does not rule out increased intracranial pressure, since it
does not develop acutely.
26. Katie is admitted to the intensive care unit of
Nurseslabs Medical Center for diabetic ketoacidosis.
Which of the following is of primary importance when
caring for the child?
A. Giving I.V. NPH insulin in high doses
B. Evaluating the child for cardiac abnormalities
C. Limiting fluids to prevent aggravating cerebral edema
D. Monitoring and recording the child's vital signs for
hypertension
As the fluid volume deficit is improved, total body
potassium deficiency may occur, leaving the child
vulnerable to hypokalemia and, afterward, cardiac
arrest. The nurse should monitor the cardiac cycle for
prolonged QT interval, low T wave, and depressed ST
segment, which indicate weakened heart muscle and
potential irregular heartbeat.
Option A: Regular insulin is the only insulin that can be
given I.V. NPH is an intermediate-acting insulin;
continuous low-dose infusion of rapid-acting insulin is
preferred. Short-acting or regular insulin should be
administered as a continuous IV infusion to treat
hyperglycemia and clear ketonemia. Bolus dosing of
insulin has NO role in DKA treatment in children
Option C: I.V. fluids should be given to correct
dehydration. IV fluids should also be given to treat
shock, acidosis, and dehydration. Strict “ins and outs”
fluid balance assessments should be kept.
Option D: Hypertension is more likely to happen
secondary to dehydration. DKA patients will have an
ileus and have vague, diffuse abdominal pain.
Dehydration, thirst, and polyuria are common at the time
of presentation due to glycosuria and osmotic diuresis.
27. Justine is admitted to the pediatric unit due to the
occurrence of diabetic ketoacidosis signaling a new
diagnosis of diabetes. The diabetes team explores the
cause of the episode and takes steps to prevent a
recurrence. Diabetic ketoacidosis (DKA) results from an
excessive accumulation of which of the following?
A. Sodium bicarbonate from renal compensation
B. Potassium from cell death
C. Glucose from carbohydrate metabolism
D. Ketone bodies from fat metabolism
Inability to use glucose causes lipolysis, fatty acid
oxidation, and release of ketones, resulting in metabolic
acidosis and coma. Ketones accumulate and cause
metabolic acidosis. The body tries to compensate by
hyperventilation to eliminate carbon dioxide. When the
blood glucose is low or cannot be used due to a lack of
insulin, ketones are the major source of energy for the
brain. The brain does not have any fuel stores and has
no other non-glucose-derived energy sources.
Option A: Sodium bicarbonate administration is a
treatment for DKA, not a cause. The rationale for
bicarbonate therapy is the theoretical assumption that
severe acidosis could contribute to organ malfunction,
such as in the liver, heart, and brain. If the arterial pH is
below 7.0 after 1 hour of hydration, bicarbonate therapy
should be used.
Option B: Potassium depletion, not potassium excess,
occurs in DKA. A transfer of potassium from the
intracellular to the extracellular space in a switch with
hydrogen ions that accumulate extracellularly in acidosis
causes blood potassium loss. Much of the shifted
extracellular potassium is eliminated in the urine,
creating total body hypokalemia.
Option C: Inability to use glucose, not impaired
carbohydrate metabolism, is the primary mechanism of
diabetes mellitus. Ketone bodies, while always present
in the blood, increase to pathologic levels when the body
cannot utilize glucose: low blood glucose levels during
fasting, starvation, vigorous exercise, or secondary to a
defect in insulin production.
28. Tara is an 11-year-old girl diagnosed with type 1
diabetes mellitus (DM). She asks her attending nurse
why she can’t take a pill rather than shots like her
grandmother does. Which of the following would be the
nurse’s best reply?
A. "If your blood glucose levels are controlled, you can
switch to using pills."
B. "The pills correct fat and protein metabolism, not
carbohydrate metabolism."
C. "Your body does not make insulin, so the insulin
injections help to replace it."
D. "The pills work on the adult pancreas, you can switch
when you are 18."
The child has type 1 DM, indicating a lack of functioning
pancreatic beta cells and an absolute insulin deficiency.
Type 1 diabetes is an autoimmune condition that leads
to the destruction of pancreatic beta cells which in turn
causes insufficient insulin production, resulting in
hyperglycemia. Type 1 diabetes is a chronic disease
requiring insulin replacement and intensive effort by the
patient.
Option A: Oral antidiabetics are indicated only for those
with some functioning beta cells, as in those with type 2
DM. Therefore, injections are indicated to supply insulin
that is lacking in type 1 diabetes.
Option B: Oral antidiabetics do not correct metabolism.
Healthcare practitioners encourage patients to combine
lifestyle modifications with oral pharmacologic agents for
optimal glycemic control, particularly as type 2 diabetes
mellitus progresses with continued loss of pancreatic
beta-cell function and insulin production.
Option D: A child with type 1 DM cannot substitute an
oral antidiabetic for insulin, regardless of age. 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.
29. Arvic who is diagnosed with diabetes mellitus type 1
displays symptoms of hypoglycemia. Which of the
following actions should the nurse instruct the parents?
A. Give the child honey (simple sugar)
B. Give the child milk (complex sugar).
C. Contact the healthcare provider before doing
anything.
D. Give the child nothing by mouth.
Immediate action is important. Therefore, providing little
sugar temporarily corrects low serum glucose levels.
Simple sugar is preferred because it is converted to
glucose more quickly than complex sugar. A child with
hyperglycemia needs fluid to prevent dehydration.
Patients should be advised to wear a medical alert
bracelet and to carry a glucose source like gel, candy, or
tablets on their person in case symptoms arise.
Option B: Because complex sugars, such as milk, are
absorbed more slowly, they do not provide an immediate
response. For patients unable to take oral agents, a 1-
mg intramuscular (IM) injection of glucagon can be
administered. Once the patient is more awake, a
complex carbohydrate food source should be given to
the patient to achieve sustained euglycemia.
Option C: Contacting the healthcare provider wastes
valuable time during which emergency measures could
be started to raise the child’s glucose level.
Nonpharmacological management of recurrent
hypoglycemia involves patient education and lifestyle
changes. Some patients are unaware of the serious
ramifications of persistent hypoglycemia. As such,
patients should be educated on the importance of
routine blood glucose monitoring as well as on the
identification of the individual’s symptoms of
hypoglycemia.
Option D: Prompt action is required to prevent
complications of hypoglycemia. Glycemic control has
been an important aspect of medical management due
to the association between glycated hemoglobin levels
and cardiovascular events in diabetes mellitus type 1
patients.
30. Which of the following should the nurse include in
the insulin administration instruction for the parents of a
child being discharged on insulin?
A. Insert the needle and aspirate prior to injecting
B. Inject insulin into the extremity to be exercised to
enhance absorption
C. The muscles in the abdomen and thigh are the
easiest to use for self-administration
D. Clean the site of injection with soap and water
and avoid alcohol
Infection risk from insulin injections is negligible (at least
in normal environments – some experts feel hospital
environments are riskier), and an alcohol swab is a poor
way to sanitize skin in the first place. Soap and hot
water are actually more effective.
Option A: Injections are made into the subcutaneous
tissue. Routine aspiration (drawing back on the injected
syringe to check for blood) is not necessary. Particularly
with the use of insulin pens, the needle should be
embedded within the skin for 5 s after the complete
depression of the plunger to ensure complete delivery of
the insulin dose.
Option B: Insulin may be injected into the subcutaneous
tissue of the upper arm and the anterior and lateral
aspects of the thigh, buttocks, and abdomen (with the
exception of a circle with a 2-inch radius around the
navel).
Option C: The subcutaneous route is the most
widespread route of administration and is preferred by
most patients due to its ease and convenience in
administration. Patients use the subcutaneous route in
the form of insulin syringes, pens, and p
31. A spica cast was put on Baby Betty after an
unfortunate incident to immobilize her hips and thighs.
Which of the following is the priority nursing action
immediately after application?
A. Keep the cast dry and clean.
B. Cover the perineal area.
C. Elevate the cast.
D. Perform neurovascular checks.
A neurovascular assessment is always a priority in the
assessment of a freshly applied cast to ensure adequate
circulation and neurologic function and prevent
complications or injury. Neurovascular observations
should be conducted hourly for the first 24 hours then 2-
4 hourly for the next 48 hours depending on the
condition. Document findings on appropriate limb
observation flowsheet.
Option A: Keeping the cast dry and clean is also
important, but this is not the priority immediately after a
cast is applied. Keeping the cast clean and dry is
essential as wetness or soiling encourages microbial
growth, which can cause skin irritation, odor and
compromise the integrity of the cast. Plaster can take up
to 24- 48 hours to dry post-application. If the plaster is
taking a long time to dry, the patient can be placed
prone to help circulate air.
Option B: Covering the perineal area to prevent
wetness and soiling is also important, but this is not the
priority immediately after a cast is applied. Nappies need
to be checked every 2 hours during the day and 3-4
hourly overnight. They must be changed as soon as
they are soiled or wet to prevent soiling/ wetting the
plaster and to avoid skin breakdown and irritation.
Option C: Elevating the cast to prevent or minimize
edema is also important, but this is not the priority
immediately after a cast is applied. Children in hip
spicas cannot move themselves easily. Regular
pressure area care is necessary due to the risk of
pressure injury. The child should be repositioned 2-4
hourly, during the day and night. The child can be
placed supine, prone or on their side if comfortable, and
must be supported with pillows and/or towels to alleviate
any pressure from the plaster, and to provide support.
Ensure the child is supervised while lying prone to
ensure monitoring of airway.
32. Among toddlers and children up to age five, femur
fractures usually result from a low energy fall. In most
cases, the orthopedic surgeon realigns the fracture
using fluoroscopy or x-ray imaging as a guide and
immobilizes the leg in a type of cast called a spica cast.
Approximately how many weeks does it take for a
fractured femur to heal in a 3-year-old?
A. 1-2 weeks
B. 2-4 weeks
C. 3-8 weeks
D. 10-12 weeks
In most cases, three to six weeks of early healing is
necessary before the child can begin walking on the
injured leg. When the bone is completely healed, usually
around one year after the injury occurs, the child returns
to the hospital to have the nails removed. Following
treatment, the orthopedic surgeon continues to monitor
the patient for a period of several years to ensure that
there is no limb length discrepancy.
Option A: 1-2 weeks of bone healing is unlikely even
among toddlers. Unlike the healing process in adults, a
certain amount of variation in the alignment of the bone
as it heals is acceptable in infants and older children,
notes Dr. Scher. As the body lays down new bone, over
time, there is an automatic “correction” or straightening
during growth, called remodeling.
Option B: The approximate healing time for a fractured
femur during childhood is 4 weeks. Fractures in these
very young children and in infants are usually treated by
placing the child in a Pavlik harness, a cloth brace that
helps hold the thigh in the proper position while it heals.
According to Dr. David M. Scher, an associate
orthopedic surgeon at the Hospital for Special Surgery,
an infant’s bones may heal very rapidly, usually by 3-4
weeks.
Option D: Children remain in the spica cast for a period
ranging from six weeks to three months, which can be a
challenge for caregivers when it comes to maintaining
hygiene and keeping the child distracted and happy.
That being said, it continues to be the safest and least
complicated method for treating fractures among this
age group and yields excellent results.
33. Mrs. Lodge’s child requires the use of a Pavlik
harness. Which of the following would Nurse Betty do to
best assess the mother’s ability to care for her child?
A. Demonstrate to the mother how to remove and
reapply the device.
B. Have the mother remove and reapply the harness
before discharge.
C. Have the mother verbalize the purpose of using the
device.
D. Request a home health care nurse visit after
discharge.
Having the mother remove and reapply the harness
before discharge allows the nurse to directly observe the
mother’s method and comfort level. It also provides time
for reinstruction if needed. A successful transition also
depends on whether hospitals have adequately
educated patients about key elements of care such as
diagnosis and follow-up plans.

Option A: Although the nurse’s demonstration is a good
teaching method, it does not permit evaluation of the
mother’s routine. A safe and patient-centered passage
from the hospital should therefore include consistent and
high-quality provision of transitional care (e.g., follow-up
appointments, comprehensive and intelligible discharge
instructions) should ensure that patients understand key
aspects of the transition and should be patient-centered
(e.g., provide adequate notice of and preparation for
discharge, result in high levels of satisfaction).
Option C: Verbalization is significant to allow the nurse
to assess the mother’s understanding, but it does not
allow evaluation of the mother’s psychomotor skills.
Although these assessments are important, simply
documenting that information is conveyed or that
patients are satisfied with practice may not be a
sufficient measure of transition success.
Option D: Requesting a home visit is a further means of
evaluation but does not provide instant feedback.
Evaluation of hospital discharge practice has often
focused on chart documentation of specific processes
and more recently, on patient satisfaction with discharge
care.
34. You have learned that in babies and children with
developmental dysplasia (dislocation) of the hip (DDH),
the hip joint has not formed normally. Which of the
following is the most common form of DDH?
A. Acetabular dysplasia
B. Dislocation
C. Preluxation
D. Subluxation
DDH is a group of congenital abnormalities of the hip
joints, which includes subluxation, dislocation, and
preluxation. Of the types of congenital hip abnormalities,
subluxation is the most common. In mild cases of DDH,
the head of the femur is simply loose in the socket.
During a physical examination, the bone can be moved
within the socket, but it will not dislocate.
Option A: Preluxation, also known as acetabular
dysplasia, is the mildest form. Acetabular dysplasia can
be a result of developmental dislocation of the hip (DDH)
that was treated in infancy or childhood. Acetabular
dysplasia can exist as a mild issue that can take years
to decades for symptoms to develop.
Option B: Dislocation is complete displacement of the
femoral head out of the acetabulum. In the most severe
cases of DDH, the head of the femur is completely out of
the socket.
Option C: Acetabular dysplasia, or hip dysplasia, is a
disorder that occurs when the acetabulum (hip socket) is
shallow and doesn’t provide sufficient coverage of the
femoral head (ball), causing instability of the hip joint.
Patients who have been diagnosed with acetabular
dysplasia often have a family history of early hip
osteoarthritis or hip dysplasia.
35. Match the traction methods to their corresponding
descriptions:
Buck's traction: hips flexed 90 degrees, both legs
Russell's traction: legs in an extended position
Bryant's traction: leg extended, knee flexed
Buck’s traction is a type of skin traction with the legs in
an extended position. It is used primarily for short-term
immobilization, preoperatively with dislocated hips, for
correcting contractures, or for bone deformities such as
Legg-Calvé-Perthes disease.
Russell’s traction uses skin traction on the lower leg and
a padded sling under the knee. The combination of
longitudinal and perpendicular traction allows
realignment of the lower extremity and immobilizes the
hips and knees in a flexed position.
Bryant’s traction is skin traction with the legs flexed at a
90-degree angle at the hip. Modified Bryant’s Traction is
used mainly to help reduce congenital hip dislocation.
When the child is lying on his back, the traction holds
the legs upright and the weight on the traction gently
stretches the child’s leg. This loosens the ligaments,
tendons, and muscles around the child’s hip.
36. Sickle cell disease (SCD) primarily affects:
A. children of African descent and Hispanics of
Caribbean ancestry.
B. children of Middle-Eastern and Indian descent.
C. children of Asian descent.
D. both African descent and Hispanics of Caribbean
ancestry and Middle-Eastern and Indian descent.
Sickle cell disease primarily affects children of African
descent and Hispanics of Caribbean ancestry. It also
occurs in children of Middle-Eastern and Indian descent.
Sickle cell anemia is the most common monogenic
disorder. Prevalence of the disease is high among the
people of Sub-Saharan Africa, South Asia, the Middle
East, and the Mediterranean.
Option A: Sickle cell disease (SCD) is a multisystem
disorder and the most common genetic disease in the
United States, affecting 1 in 500 African Americans.
About 1 in 12 African Americans carry the autosomal
recessive mutation, and approximately 300,000 infants
are born with sickle cell anemia annually.
Option B: Sickle cell disease (SCD) affects millions of
people throughout the world and is particularly common
among those whose ancestors came from sub-Saharan
Africa; Spanish-speaking regions in the Western
Hemisphere (South America, the Caribbean, and
Central America); Saudi Arabia; India; and
Mediterranean countries such as Turkey, Greece, and
Italy.
Option C: In Europe and Africa, when there is a high
frequency of the malaria parasite, there is a high
frequency of the sickle-cell allele. In Asia, the frequency
of the sickle cell allele is very low, regardless of the
frequency of malaria parasites present.
37. Nurse Christine is planning a client education
program for sickle cell disease (SCD) in children. Which
of the following interventions would be included in the
care plan?
A. Health teaching to help reduce sickling crises
B. Avoidance of the use of opioids
C. Administration of an anticoagulant to prevent sickling
D. Observation of the imposed fluid restriction
Prevention is one of the principal goals of therapeutic
management because there is no cure for sickle cell
disease. Consequently, health education to help lessen
the sickling crisis is key. Early detection and rapid
initiation of appropriate treatment for several acute
conditions including the vaso-occlusive crisis, aplastic
crisis, sequestration crisis, and hemolytic crisis is
needed. These crises, if not treated early, can result in
mortality.
Option B: Opioids usually are required for pain control.
Most guidelines recommend early initiation of parenteral
opioid analgesics, usually with morphine at 0.1 mg/kg IV
or subcutaneously (SC) every 20 minutes, and
maintaining this analgesia with morphine at doses of
0.05 to 0.1 mg/ kg every 2 to 4 hrs (SC/IV or PO).
Option C: Anticoagulants do not prevent sickling.
Adjuvant therapy includes hydroxyurea, antihistamines,
anxiolytics, and antiemetics. It is prudent to maintain
adequate hydration and be vigilant in identifying other
causes of pain that may need additional treatment.
Option D: Fluids are encouraged to increase fluid
volume and prevent sickling. The key is rapid hydration
and pain control. In addition, oxygenation should be
monitored. It is important to find and treat the trigger of
the crisis to prevent a recurrent crisis.
38. Mrs. Baker was instructed by the nurse on foods to
encourage her child’s diet concerning the latter’s iron
deficiency anemia. which of the following if stated by the
mother would indicate the need for further instruction?
A. Fish
B. Lean meats
C. Whole-grain breads
D. Yellow vegetables
If a parent states that she should stress the intake of
yellow vegetables, she needs additional teaching
because yellow vegetables are not a good source of
iron. Leafy greens, especially dark ones, are among the
best sources of nonheme iron.
Option A: Some seafood provides heme iron. Shellfish
such as oysters, clams, scallops, crabs, and shrimp are
good sources. Most fish contain iron. Although canned
sardines are good sources of iron, they’re also high in
calcium. Calcium may bind with iron and reduce its
absorption.
Option B: All meat and poultry contain heme iron. Red
meat, lamb, and venison are the best sources. Poultry
and chicken have lower amounts. Eating meat or poultry
with nonheme iron foods, such as leafy greens, along
with vitamin C-rich fruit can increase iron absorption.
Option C: Whole-grain breads are good food source of
iron and should be supported and encouraged. It may
be a good idea to choose iron-fortified cereals, bread
products, orange juice, rice, and pasta. Also, fermented
and sprouted grains and legumes are a better choice for
people with iron deficiency because sprouting and
fermenting break down anti-nutrient compounds that
negatively impact iron absorption.
39. The long-term complications seen in thalassemia
major are associated to which of the following?
A. Anemia
B. Growth retardation
C. Hemochromatosis
D. Splenomegaly
Long-term complications arise from hemochromatosis,
excessive iron deposits precipitating in the tissues, and
causing destruction. Hemochromatosis is a disorder
associated with deposits of excess iron that causes
multiple organ dysfunction. Hemochromatosis occurs
when there are high pathologic levels of iron
accumulation in the body. Hemochromatosis has been
called “bronze diabetes” due to the discoloration of the
skin and associated disease of the pancreas.
Option A: Anemia is a sign of this disorder. Skin can
show pallor due to anemia and jaundice due to
hyperbilirubinemia resulting from intravascular
hemolysis. Patients usually report fatigue due to anemia
as the first presenting symptom.
Option B: Anemia can inhibit a child’s growth rate, and
thalassemia can cause a delay in puberty. Particular
attention should focus on the child’s growth and
development according to age.
Option D: Cellular damage from hemochromatosis may
lead to splenomegaly. Hepatosplenomegaly can result
from chronic iron deposition and also from
extramedullary hematopoiesis in these organs. Splenic
infarcts or autophagy result from chronic hemolysis due
to poorly regulated hematopoiesis.
40. Archie is a child with iron deficiency anemia. He is
required to receive elemental iron therapy at 6
mg/kg/day in three divided doses. He weighs 44 lbs.
How many milligrams of iron should he receive per
dose?
A. 20 mg/dose
B. 40 mg/dose
C. 60 mg/dose
D. 120 mg/dose
The child weighs 44 lbs, which is equal to 20 kg (1
kg=2.2 lb;44/2.2=20kg). Elemental iron therapy is
ordered at 6 mg/kg/day in three doses. Therefore, the
child receives 120 mg/day (6 mg/20 kg/day=120),
divided into three doses (120/3), which is equal to 40
mg/dose.
Option A: There are currently two forms of low-
molecular-weight iron dextran available on the market in
North American. Both come as injectable solutions
[intravenous (IV) or intramuscular (IM)] containing 50
mg/mL of elemental iron. The incidence of toxicity
relative to high-molecular-weight preparations is lower
with low-molecular-weight iron dextran.
Option C: As per the manufacturer, a test dose of 25
mg (0.5 mL) followed by 1 hour of observation is
necessary before administering the remainder of the
calculated required dose to monitor for anaphylactoid
reactions. Intramuscular injections should be
administered to the upper outer quadrant of the buttock
using the Z – track technique (lateral displacement of
skin prior to injection).
Option D: If total dose calculations exceed the daily
allowance of administration, smaller incremental daily
doses may be used until the patient achieves the total
dose requirement. All doses require administration at a
maximum rate of 50 mg (1 mL) per minute. No dosage
adjustments are necessary for renal and/or hepatic
impairment.
41. Martin Sanchez is a nine (9)-year-old child admitted
to a psychiatric treatment unit accompanied by Mr. and
Mrs. Sanchez. To establish trust and position of
neutrality, which action would the nurse take?
A. Encourage Mr. and Mrs. Sanchez to leave while
Martin is being interviewed.
B. Interview Martin with his parents together,
observing their interaction.
C. Provide diversion for Martin, and interview Mr. and
Mrs. Sanchez alone.
D. Review the clinical record prior to interviewing Mr.
and Mrs. Sanchez.
It is important for the nurse to be seen as a neutral
person who is interested in the family as an adaptive
functioning unit. By conducting the admission interview
with the parents and child together, the nurse
establishes this neutral role from the beginning.
Relationships with child and adolescent patients differ
from those with adult patients and nurses build
relationships in a different way with adults.
Option A: In child and adolescent inpatient psychiatric
care, the efficacy of treatment depends upon the nurses’
ability to build intimate patient-nurse relationships. The
quality of therapeutic relationships has a large influence
on the success of any interventions with children and
families.
Option C: The response on option C separates the
parents and the child, and thus the nurse does not have
an opportunity to establish a position of neutrality.
Nurses are trained to have good interpersonal skills
because positive therapeutic alliance is one of the
predictors of better treatment outcomes.
Option D: Although the nurse would review the clinical
record, this does not demonstrate to the family that she
is an advocate for both parents and the child. The
substantive theory which addresses child and
adolescent inpatient psychiatric care is required for
enhancing the quality of patient-nurse relationships and
achieving patients’ outcomes.
42. Which behavioral assessment in a child is most
consistent with a diagnosis of conduct disorder?
A. Arguing with adults
B. Gross impairment in communication
C. Physical aggression toward others
D. Refusal to separate from caretaker
Physical aggression toward others is a significant
criterion consistent with the diagnoses of conduct
disorder. Conduct disorder (CD) lies on a spectrum of
disruptive behavioral disorders, which also include
oppositional defiant disorder (ODD). In some cases,
ODD is a precursor to CD. CD is characterized by a
pattern of behaviors that demonstrate aggression and
violation of the rights of others and evolves over time.
Option A: Arguing with adults may indicate a lesser
disorder, oppositional defiant disorder. Conduct disorder
is a problem that involves a violation of social rules.
Oppositional defiant disorder (ODD) is a type of
childhood disruptive behavior disorder that primarily
involves problems with the self-control of emotions and
behaviors.
Option B: Gross impairment in communication can be a
sign of autism. Autism is a neurodevelopmental disorder
characterized by severe impairment in reciprocal social
interactions and communication skills, as well as the
presence of restricted and stereotypical behaviors.
Option D: Refusal to separate from a caretaker is a
behavior that is more consistent with other mental
disorders that can affect children. Anxiety disorders are
characterized by excessive or inappropriate fear, with
associated behavioral disturbances that impair
functioning (APA 2013). Children with anxiety disorders
have clinical symptoms, such as excessive anxiety;
severe physiological anxiety symptoms; behavioral
disturbances, such as avoidance of feared objects; and
associated distress or impairment.
43. The community nurse visits the home of George, a
child recently diagnosed with autism. The parents
express feelings of shame and guilt about having
somehow caused this problem. Which statement by the
nurse would best help alleviate parental guilt?
A. "Autism is a rare disorder. Your other children
shouldn't be affected."
B. "The specific cause of autism is unknown.
However, it is known to be associated with problems
in the structure of and chemicals in the brain."
C. "Sometimes a lack of prenatal care can be the cause
of autism."
D. "Although autism is genetically inherited if you didn't
have testing you could not have known this would
happen."
This statement is factual and does not cast blame on
anything the parents did or did not do. The cause is still
not known. The onset is variable. It develops in days to
weeks, while in other cases, it develops slowly. It is not
known whether epilepsy causes it, but children that have
an autism spectrum disorder have an increased risk of
having epilepsy.
Option A: The parents are not questioning whether
other children will be affected; their concern is directed
to the current situation and their feelings about it. Autism
spectrum disorder is becoming increasingly prevalent,
and its prevalence is reported to be 1 in 68. Childhood
disintegrative disorder is a rare disease, with only 1.7 in
100,000 cases, and the prevalence of this disease is
estimated to be 1 to 2 in 100,000.
Option C: Lack of prenatal care may be a risk factor in
pervasive developmental disorders, but it is not the
cause of autism. There is no clear-cut pathology of the
disease, so the causes of childhood disintegrative
disorder are still unknown. Regression occurs in children
who have achieved normal developmental milestones,
and this regression sometimes occurs very rapidly.
Option D: Although it is thought that there is a genetic
component in autism, research has not identified
specific genes, and there is no diagnostic test for this.
The statement is misleading and would not alleviate
guilt. This condition develops in days or overtime and is
most commonly seen in the fourth year of life, but there
can be variation.
44. Nurse Gloria questions the parents of a child with
oppositional defiant disorder about the roles of each
parent in setting rules of behavior. The purpose of this
type of questioning is to assess which element of the
family system?
A. Anxiety levels
B. Generational boundaries
C. Knowledge of growth and development
D. Quality of communication
An important element in assessing the family system is
determining if the parents establish and maintain
appropriate generational boundaries, establishing clear
rules and expectations as part of the parental role.
Provide clear behavioral guidelines, including
consequences for disruptive and manipulative behavior.
Option A: Although the parents may have anxiety
regarding the role of parental rule-setting, the nurse’s
question is not adequate to assess the anxiety levels.
Use role-playing so he can practice ways of handling
stress and gain skill and confidence in managing difficult
situations.
Option C: Instruct patients on how to deal with a child’s
demands. This might include learning how to reinforce
appropriate behaviors. Ways to bond more strongly with
the child should be encouraged.
Option D: The question concerns the roles of the
parents and the child in a rule setting. It does not
provide data regarding knowledge of growth and
development or communication quality. Identify abusive
communication (e.g. threats, sarcasm, and disparaging
comments). Encourage the child to stop using them.
45. The school nurse assesses Brook, a child newly
diagnosed with attention deficit hyperactivity disorder
(ADHD). Which of the following symptoms are
characteristic of the disorder? Select all that apply.
A. Constant fidgeting and squirming
B. Excessive fatigue and somatic complaints
C. Difficulty paying attention to details
D. Easily distracted
E. Running away
F. Talking constantly, even when inappropriate
These behaviors are all characteristic of ADHD and
indicate that the child is inattentive, hyperactive, and
impulsive. Individuals suffering from this disorder show
patterns of developmentally inappropriate levels of
inattentiveness, hyperactivity, or impulsivity. Although
there used to be two different diagnoses of Attention
Deficit Disorder vs Attention Deficit Hyperactivity
Disorder, the DSM IV combined this into one disorder
with three subtypes: predominantly inattentive,
predominantly hyperactive, or combined type.
Option A: The symptoms begin at a young age and
usually include lack of attention, lack of concentration,
disorganization, difficulty completing tasks, being
forgetful, and losing things.
Option B: This can be a sign of emotional distress in a
child and could be associated with a number of different
psychiatric diagnoses. In order to diagnose ADHD, it is
very important to take a relevant history of the
concerned individual. ADHD is diagnosed in children
based upon their history where the children face
difficulty in at least 6 of the 9 symptoms as mentioned in
DSM 5.
Option C: This symptom must be present in more than
one setting (ie at home and at school, or at school and
at after-school activities). It can have large
consequences including social interactions, increased
risky behaviors, loss of jobs, and difficulty achieving in
school.
Option D: ADHD must be considered within the context
of what is developmentally and culturally appropriate for
a person. It is considered a dysfunction of executive
functioning, predominantly a frontal lobe activity.
Therefore, patients with ADHD show disability not only
in attention and focus but also in decision making and
emotional regulation.
Option E: For children, the Vanderbilt ADHD scale is
often used as it has both a teacher and parent
component. A physical examination, on the other hand,
is not as useful in the diagnosis of ADHD but it can still
be used to exclude medical causes such as thyroid
problems.
Option F: Children with ADHD can have difficulty with
social interactions, can be easily frustrated, and can be
impulsive. They are often labeled as “troublemakers.”
Hyperactive symptoms include: fidgeting, feeling like an
“internal motor” is always going, leaving their seat,
climbing on things, being loud, blurting out answers,
talking excessively or out of turn, having trouble waiting
their turn, interrupts, or intrudes on others. These
symptoms must be present in multiple settings.
46. A nurse prepares to administer an intramuscular
injection to a 6-month-old infant. The nurse selects
which site to administer the medication?
A. Rectus femoris
B. Dorsal gluteal
C. Ventrogluteal
D. Vastus lateralis
Intramuscular injection sites are selected based on the
child’s age and muscle development. The vastus
lateralis is the only safe muscle group to use for
intramuscular injection in a 6 month-old infant. Muscle
has fewer pain-sensing nerves than subcutaneous
tissue and is less sensitive to irritating and viscous
medications, so pain is lessened.
Option A: I.M. injections are administered in newborns
to deliver medications deeply into the muscle without
causing injury to the tiny patient. Skeletal muscle can
accommodate larger volumes of medication than
subcutaneous tissue, and absorption is faster because
muscle tissue is highly vascular.
Option B: Never give an IM injection in the buttocks.
Using the vastus lateralis muscle avoids the risk of
sciatic nerve damage from gluteal injection. Also, the
vastus lateralis muscle has a larger muscle mass than
the gluteal region and therefore has reduced risk of
severe local reactions.
Option C: The ventrogluteal site is unsafe for that age.
Avoid subcutaneous and intramuscular injections when
intravenous administration is a suitable alternative
option. Make sure that infants do not move during the IM
injection. This is very important.
47. A child was brought to the emergency department
with complaints of nausea, vomiting, fruity-scented
breath. The resident on duty diagnosed the child with
diabetes ketoacidosis. Which of the following should the
nurse expect to administer?
A. Potassium chloride IV infusion.
B. Dextrose 5% IV infusion.
C. Ringer's Lactate.
D. Normal saline IV infusion.
The initial priority in the treatment of diabetic
ketoacidosis is the restoration of extracellular fluid
volume through the intravenous administration of a
normal saline(0.9 percent sodium chloride) solution.
Treatment for DKA begins with ABCs and fluid
resuscitation. Insulin therapy, usually by continuous
infusion, can begin once the patient is stabilized.
Option A: This is not part of the initial treatment. Check
potassium regularly (and other electrolytes) to avoid
hypokalemia. Place patients on the cardiac monitor to
observe early changes in the T-waves for early
intervention. Most sources recommend obtaining serum
potassium before any insulin dosing and replacing
potassium if below 4.
Option B: Short-acting or Regular insulin should be
administered as a continuous IV infusion to treat
hyperglycemia and clear ketonemia. Bolus dosing of
insulin has NO role in DKA treatment in children.
Option C: Dextrose solutions will be used only when the
blood glucose level is decreased. IV fluids are given to
treat shock, acidosis, and dehydration. Strict “ins and
outs” fluid balance assessments should be kept.
48. Hydrocortisone cream 1% is given to a child with
eczema. The nurse gives instruction to the mother to
apply the cream by?
A. Apply a thin layer of cream and spread it into the
area thoroughly.
B. Avoid cleansing the area before the application.
C. Apply a thick layer of the cream to affected areas
only.
D. Apply the cream to other areas to avoid occurrence.
Topical corticosteroids are administered sparingly and
rubbed into the area thoroughly. Topical steroid creams
and ointments should be applied in a thin layer and
massaged into the affected area.
Option B: The area should be cleaned first before
administration. Because topical steroids can cause side
effects, the spacing of intermittent applications should
be discussed with a healthcare provider before
proceeding.
Option C: Different surfaces of the skin absorb topical
steroids differently. Therefore the strength of the steroid
should correspond to the type of skin where it is to be
applied. The greater the steroid group number, the
greater the risk of side effects.
Option D: Rubbing it in other areas will likely lead to
systemic absorption. Infants and young children have
skin that absorbs topical steroids more readily, also
requiring a low-potency steroid.
49. A child with known hemophilia A was brought to the
emergency room with complaints of nose bleeding and
some bruises in the joints. Which of the following should
the nurse anticipate to be given to the child?
A. Oral iron supplement
B. Cyclosporine
C. Factor X
D. Factor VIII
Hemophilia A, also called factor VIII (FVIII) deficiency or
classic hemophilia, is a genetic disorder caused by
missing or defective factor VIII, a clotting protein. The
initial treatment is the administration of factor VIII to
replace the missing factor and decrease the bleeding
episode.
Option A: Oral iron supplement is not used in the
management of hemophilia. Other pharmaceutical
adjuvant therapies for hemophilia A-induced bleeding
include desmopressin, tranexamic acid, epsilon
aminocaproic acid, and management of factor VIII
inhibitors.
Option B: Cyclosporine is an immunosuppressive agent
used to treat organ rejection post-transplant. It also has
use in certain other autoimmune diseases, treatment of
organ rejection in kidney, liver, and heart allogeneic
transplants, rheumatoid arthritis when the condition has
not adequately responded to methotrexate.
Option C: Hemophilia, which means love (philia) of
blood (hemo), is the most common severe hereditary
hemorrhagic disorder. Both hemophilia A and B result
from factor VIII and factor IX protein deficiency or
dysfunction, respectively, and are characterized by
prolonged and excessive bleeding after minor trauma or
sometimes even spontaneously.
50. Which of the following is not true regarding the
varicella vaccine?
 A. It is administered subcutaneously.
B. Children 13 years and older (With no history of
chickenpox or have not previously vaccinated) need two
doses given at least 28 days apart.
C. Give aspirin for any injection-related pain.
D. The most common mild side effects are pain,
redness, or swelling at the injection site.

Children receiving the varicella vaccine should avoid

aspirin or aspirin-containing products because of the risk
of Reye’s syndrome. After administration of the vaccine,
it is recommended to avoid salicylates for five weeks
due to the risk of Reye’s syndrome and to avoid contact
with susceptible high-risk individuals.

Option A: The varicella vaccine is only available to be

administered subcutaneously. It is best when
practitioners inject the vaccine in the outer aspect of the
upper arm in the deltoid region or anterolateral thigh.
Option B: The first dose is given to children between 12
to 15 months of age, and administration of the second
dose is for children between 4 to 6 years old. If three
months have passed since the first dose, one may opt to
give the second dose earlier. If a child has never been
vaccinated or had chickenpox, the practitioner should
give the two doses at least 28 days apart.
Option D: The most commonly reported adverse effect
is soreness or swelling at the injection site. Some other
mild reported reactions include fever and mild vaccine-
associated varicelliform rash. The rash comprises six to
ten papular, vesicular, erythematous lesions which peak
around eight to 21 days after injection.