PNR 204/PNR204 Exam 2 V3 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a 2-year-old child who is hospitalized. The child is crying and screaming
for their parents. Which stage of separation anxiety is the child demonstrating?
A. Denial
B. Despair
C. Protest
D. Detachment
Correct Answer: C
Expert Explanation: The stage of protest is characterized by crying, screaming, and
searching for the parents while rejecting contact with strangers. This is a normal and
healthy response for a toddler who is experiencing the stress of hospitalization. In the later
stage of despair, the child becomes quiet and withdrawn, while detachment involves a
superficial adjustment where the child ignores parents upon their return.
2. Which clinical manifestation should a nurse expect to find in a child diagnosed with pyloric
stenosis?
A. Projectile vomiting after feedings
B. Ribbon-like stools
,C. Currant jelly-like stools
D. Steatorrhea
Correct Answer: A
Expert Explanation: Projectile vomiting is the classic hallmark sign of hypertrophic
pyloric stenosis due to the mechanical obstruction of the gastric outlet. This usually occurs
shortly after feeding and does not contain bile because the obstruction is proximal to the
ampulla of Vater. The nurse may also palpate an olive-shaped mass in the right upper
quadrant during physical assessment.
3. A 4-year-old child is brought to the emergency department with suspected epiglottitis.
Which action should the nurse take first?
A. Maintain the child in an upright position and keep them calm.
B. Visualize the throat using a tongue depressor.
C. Obtain a throat culture to identify the pathogen.
D. Prepare the child for an immediate chest X-ray.
Correct Answer: A
Expert Explanation: Epiglottitis is a medical emergency that can lead to sudden airway
obstruction if the child becomes agitated or if the throat is stimulated. The nurse must
never use a tongue depressor or attempt a throat culture as this can trigger a fatal
laryngospasm. Keeping the child calm and in a position of comfort, usually sitting upright in
the tripod position, is the priority to maintain airway patency.
, 4. A nurse is teaching the parents of a child with Cystic Fibrosis about dietary requirements.
Which instruction is most important to include?
A. Restrict salt intake during the summer months.
B. Administer pancreatic enzymes with all meals and snacks.
C. Provide a low-protein, low-calorie diet.
D. Limit fluid intake to prevent pulmonary congestion.
Correct Answer: B
Expert Explanation: Children with Cystic Fibrosis have pancreatic insufficiency, meaning
they cannot effectively digest fats and proteins without supplemental enzymes. These
enzymes must be taken every time the child eats to ensure nutrient absorption and prevent
malnourishment. Additionally, these children require a high-calorie, high-protein diet to
support growth and compensate for their high metabolic demands.
5. A 10-month-old infant is admitted with severe dehydration. Which of the following
findings would the nurse expect to see?
A. Bulging fontanels and bradycardia
B. Moist mucous membranes and brisk capillary refill
C. Sunken fontanels and decreased urine output
D. Increased skin turgor and hypertension
Correct Answer: C
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a 2-year-old child who is hospitalized. The child is crying and screaming
for their parents. Which stage of separation anxiety is the child demonstrating?
A. Denial
B. Despair
C. Protest
D. Detachment
Correct Answer: C
Expert Explanation: The stage of protest is characterized by crying, screaming, and
searching for the parents while rejecting contact with strangers. This is a normal and
healthy response for a toddler who is experiencing the stress of hospitalization. In the later
stage of despair, the child becomes quiet and withdrawn, while detachment involves a
superficial adjustment where the child ignores parents upon their return.
2. Which clinical manifestation should a nurse expect to find in a child diagnosed with pyloric
stenosis?
A. Projectile vomiting after feedings
B. Ribbon-like stools
,C. Currant jelly-like stools
D. Steatorrhea
Correct Answer: A
Expert Explanation: Projectile vomiting is the classic hallmark sign of hypertrophic
pyloric stenosis due to the mechanical obstruction of the gastric outlet. This usually occurs
shortly after feeding and does not contain bile because the obstruction is proximal to the
ampulla of Vater. The nurse may also palpate an olive-shaped mass in the right upper
quadrant during physical assessment.
3. A 4-year-old child is brought to the emergency department with suspected epiglottitis.
Which action should the nurse take first?
A. Maintain the child in an upright position and keep them calm.
B. Visualize the throat using a tongue depressor.
C. Obtain a throat culture to identify the pathogen.
D. Prepare the child for an immediate chest X-ray.
Correct Answer: A
Expert Explanation: Epiglottitis is a medical emergency that can lead to sudden airway
obstruction if the child becomes agitated or if the throat is stimulated. The nurse must
never use a tongue depressor or attempt a throat culture as this can trigger a fatal
laryngospasm. Keeping the child calm and in a position of comfort, usually sitting upright in
the tripod position, is the priority to maintain airway patency.
, 4. A nurse is teaching the parents of a child with Cystic Fibrosis about dietary requirements.
Which instruction is most important to include?
A. Restrict salt intake during the summer months.
B. Administer pancreatic enzymes with all meals and snacks.
C. Provide a low-protein, low-calorie diet.
D. Limit fluid intake to prevent pulmonary congestion.
Correct Answer: B
Expert Explanation: Children with Cystic Fibrosis have pancreatic insufficiency, meaning
they cannot effectively digest fats and proteins without supplemental enzymes. These
enzymes must be taken every time the child eats to ensure nutrient absorption and prevent
malnourishment. Additionally, these children require a high-calorie, high-protein diet to
support growth and compensate for their high metabolic demands.
5. A 10-month-old infant is admitted with severe dehydration. Which of the following
findings would the nurse expect to see?
A. Bulging fontanels and bradycardia
B. Moist mucous membranes and brisk capillary refill
C. Sunken fontanels and decreased urine output
D. Increased skin turgor and hypertension
Correct Answer: C
