|Rationales
1. According to Erikson, what is the primary developmental task for a toddler
(ages 1 to 3 years)?
A. Trust vs. Mistrust
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame and Doubt
Answer: D
Rationale: Toddlers are working on establishing independence and self-control, which is
the stage of Autonomy vs. Shame and Doubt.
2. Which clinical manifestation is most characteristic of acute epiglottitis?
A. Barking cough
B. Low-grade fever
C. Drooling and tripod positioning
D. Expiratory wheezing
Answer: C
Rationale: Epiglottitis is a medical emergency characterized by the ‘4 Ds’: Drooling,
Dysphagia, Dysphonia, and Distressed inspiratory efforts, often with tripod positioning.
,3. A child with Cystic Fibrosis is receiving pancreatic enzymes. The nurse should
instruct the parents to administer them:
A. Once daily in the morning
B. With every meal and snack
C. Only if the child has a bowel movement
D. Two hours after eating
Answer: B
Rationale: Pancreatic enzymes must be taken with all meals and snacks to ensure the
absorption of nutrients and fats.
4. Which of the following is an early sign of Digoxin toxicity in a child?
A. Hypertension
B. Increased appetite
C. Tachycardia
D. Nausea and vomiting
Answer: D
Rationale: Gastrointestinal symptoms like nausea, vomiting, and anorexia are common
early signs of Digoxin toxicity in the pediatric population.
5. A child with Tetralogy of Fallot experiences a ‘Tet spell.’ What is the nurse’s
priority action?
A. Administer oxygen via mask
B. Place the child in a knee-chest position
C. Prepare for immediate intubation
D. Administer intravenous fluids
Answer: B
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation.
, 6. When caring for a child in a sickle cell crisis, which intervention is the highest
priority?
A. Providing pain relief
B. Administering antibiotics
C. Encouraging physical activity
D. Intravenous hydration
Answer: D
Rationale: Hydration is the priority to reduce blood viscosity and prevent further sickling
of red blood cells during a vaso-occlusive crisis.
7. The nurse is assessing an infant for suspected pyloric stenosis. Which finding
is most expected?
A. Projectile vomiting
B. Currant jelly stools
C. Chronic diarrhea
D. Abdominal distension
Answer: A
Rationale: Hypertrophic pyloric stenosis typically presents with non-bile stained,
projectile vomiting after feedings.
8. What type of stool is characteristic of a child with intussusception?
A. Ribbon-like and foul smelling
B. Loose and green
C. Currant jelly-like
D. Hard and marble-like
Answer: C
Rationale: Intussusception causes the passage of ‘currant jelly’ stools, which are composed
of blood and mucus.