PNR 204/PNR204 Final Exam V3 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A 2-year-old child is admitted with a diagnosis of croup. Which clinical manifestation
should the nurse prioritize during the assessment?
A. Expantory wheezing and tachypnea
B. High fever and drooling
C. Productive cough with thick green mucus
D. Barking cough and inspiratory stridor
Correct Answer: D
Expert Explanation: Croup is characterized by inflammation of the larynx and trachea
which leads to a distinct barking cough and inspiratory stridor. This condition typically
worsens at night and may cause varying degrees of respiratory distress. Assessing the
airway and respiratory effort is the primary nursing responsibility in these patients.
2. According to Erikson’s stages of psychosocial development, which task is primary for a 4-
year-old child?
A. Initiative vs. Guilt
B. Autonomy vs. Shame and Doubt
C. Trust vs. Mistrust
,D. Industry vs. Inferiority
Correct Answer: A
Expert Explanation: The preschool-age child, ranging from 3 to 6 years, is in the stage of
Initiative vs. Guilt. During this period, children begin to assert power and control over their
environment through play and social interaction. If they are discouraged or punished for
their attempts at independence, they may develop a sense of guilt.
3. A nurse is caring for an infant with pyloric stenosis. Which finding is the hallmark sign of
this condition?
A. Currant jelly-like stools
B. Abdominal distension and bile-stained emesis
C. Projectile vomiting after feedings
D. Ribbon-like, foul-smelling stools
Correct Answer: C
Expert Explanation: Pyloric stenosis involves the thickening of the pyloric sphincter,
which obstructs gastric emptying. This results in projectile vomiting, which typically occurs
shortly after feeding and does not contain bile. Additionally, an olive-shaped mass may be
palpable in the right upper quadrant of the abdomen.
4. A child is diagnosed with Tetralogy of Fallot. The nurse observes the child squatting while
playing. What is the significance of this action?
A. It increases systemic vascular resistance to improve oxygenation
, B. It is a sign of abdominal pain or cramping
C. It helps the child rest tired leg muscles
D. It indicates the child is about to have a seizure
Correct Answer: A
Expert Explanation: Squatting is a compensatory mechanism used by children with
cyanotic heart defects like Tetralogy of Fallot. This position increases systemic vascular
resistance, which decreases the right-to-left shunt and improves pulmonary blood flow.
Nurses should recognize this as a ‘TET spell’ management technique used naturally by the
child.
5. Which dietary instruction is essential for a child newly diagnosed with Celiac disease?
A. Eliminate all dairy products from the diet
B. Follow a low-protein, high-carbohydrate diet
C. Avoid wheat, barley, rye, and oats
D. Restrict intake of citrus fruits and juices
Correct Answer: C
Expert Explanation: Celiac disease is an autoimmune disorder where the ingestion of
gluten leads to damage in the small intestine. Gluten is a protein found in wheat, barley,
and rye; oats are often excluded due to cross-contamination. Adhering to a strict gluten-
free diet is the only treatment to prevent intestinal damage and malabsorption.
Nursing Q&A with Rationale | Fortis
College
1. A 2-year-old child is admitted with a diagnosis of croup. Which clinical manifestation
should the nurse prioritize during the assessment?
A. Expantory wheezing and tachypnea
B. High fever and drooling
C. Productive cough with thick green mucus
D. Barking cough and inspiratory stridor
Correct Answer: D
Expert Explanation: Croup is characterized by inflammation of the larynx and trachea
which leads to a distinct barking cough and inspiratory stridor. This condition typically
worsens at night and may cause varying degrees of respiratory distress. Assessing the
airway and respiratory effort is the primary nursing responsibility in these patients.
2. According to Erikson’s stages of psychosocial development, which task is primary for a 4-
year-old child?
A. Initiative vs. Guilt
B. Autonomy vs. Shame and Doubt
C. Trust vs. Mistrust
,D. Industry vs. Inferiority
Correct Answer: A
Expert Explanation: The preschool-age child, ranging from 3 to 6 years, is in the stage of
Initiative vs. Guilt. During this period, children begin to assert power and control over their
environment through play and social interaction. If they are discouraged or punished for
their attempts at independence, they may develop a sense of guilt.
3. A nurse is caring for an infant with pyloric stenosis. Which finding is the hallmark sign of
this condition?
A. Currant jelly-like stools
B. Abdominal distension and bile-stained emesis
C. Projectile vomiting after feedings
D. Ribbon-like, foul-smelling stools
Correct Answer: C
Expert Explanation: Pyloric stenosis involves the thickening of the pyloric sphincter,
which obstructs gastric emptying. This results in projectile vomiting, which typically occurs
shortly after feeding and does not contain bile. Additionally, an olive-shaped mass may be
palpable in the right upper quadrant of the abdomen.
4. A child is diagnosed with Tetralogy of Fallot. The nurse observes the child squatting while
playing. What is the significance of this action?
A. It increases systemic vascular resistance to improve oxygenation
, B. It is a sign of abdominal pain or cramping
C. It helps the child rest tired leg muscles
D. It indicates the child is about to have a seizure
Correct Answer: A
Expert Explanation: Squatting is a compensatory mechanism used by children with
cyanotic heart defects like Tetralogy of Fallot. This position increases systemic vascular
resistance, which decreases the right-to-left shunt and improves pulmonary blood flow.
Nurses should recognize this as a ‘TET spell’ management technique used naturally by the
child.
5. Which dietary instruction is essential for a child newly diagnosed with Celiac disease?
A. Eliminate all dairy products from the diet
B. Follow a low-protein, high-carbohydrate diet
C. Avoid wheat, barley, rye, and oats
D. Restrict intake of citrus fruits and juices
Correct Answer: C
Expert Explanation: Celiac disease is an autoimmune disorder where the ingestion of
gluten leads to damage in the small intestine. Gluten is a protein found in wheat, barley,
and rye; oats are often excluded due to cross-contamination. Adhering to a strict gluten-
free diet is the only treatment to prevent intestinal damage and malabsorption.
