N165 Clicker Questions (Found) Exam Study Guide
You are the nurse assigned to care for a child with a basilar skull fracture. Your most
important nursing observation is change in level of consciousness. You will be highly
alert for
a. Alterations in vital signs that often appear before alterations in consciousness or
focal neurologic signs
b. Bleeding from the ear, which is indicative of an anterior basal skull fracture
c. Seizures that are relatively uncommon in children at the time of head injury
d. Changes in posturing, such as any signs of extension or flexion posturing, unusual
response to stimuli, and random versus purposeful movement - ANSWER d. Changes in
posturing, such as any signs of extension or flexion posturing, unusual response to
stimuli, and random versus purposeful movement
As the nurse assigned to a child diagnosed with bacterial meningitis, you know that
a. The child will not need to be placed in isolation because antibiotics have been started
b. Enteric precautions will remain in place for up to 48 hours
c. Respiratory isolation will remain in place for 24 hours after antibiotics are started
d. Due to headache, the child will want the head of the bed elevated with 2 pillows -
ANSWER c. Respiratory isolation will remain in place for 24 hours after antibiotics are
started
You are working with a pediatric nurse who has just transferred to the pediatric clinic.
You are role playing phone triage related to a child with a head injury. You ascertain that
the nurse needs more teaching based on what response?
a. After initial physical exam, if there was no loss of consciousness with the head injury,
the can be observed at home
b. If there is a language barrier, written instructions can be given, followed by discharge
c. Another physical exam should take place in 1 or 2 days
d. Parents should call the doctor if their child has any of these signs: blurred vision,
walking unsteadily, or is hard to awaken - ANSWER b. If there is a language barrier,
written instructions can be given, followed by discharge
You are caring for a child with hydrocephalus who is postoperative from a shunt
revision. Which assessment findings is your priority for increased intracranial pressure
,a. Nausea and refusal to eat postoperatively
b. Complain of a headache
c. Irritability and wanting to sleep
d. Decrease in heart rate over the last hour - ANSWER d. Decrease in heart rate over the
last hour
You are working with a family that drouth their child into the pediatric clinic. The mother
describes what may be a type of seizure. What subjective data will help you determine
the type? SATA
a The presence or absence of an aura
b. If the child appeared disoriented after the seizure
c. Presence of vomiting after the seizure
d. The duration of the seizure
e. If the seizure was related to certain foods or occurred after a certain activity -
ANSWER a The presence or absence of an aura
b. If the child appeared disoriented after the seizure
d. The duration of the seizure
The Glasgow Coma Scale consists of an assessment of
a. pupil reactivity and motor response.
b. level of consciousness and verbal response.
c. eye opening and verbal and motor response.
d. intracranial pressure and level of consciousness. - ANSWER c. eye opening and
verbal and motor response.
A 3-year-old child is hospitalized after submersion injury. The child's mother complains
to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply
would be which of the following?
a. "He still needs a little extra oxygen."
b. "I'm sure he is fine, but the doctor wants to make sure."
c. "It is important to observe for possible physical reasons for the accident."
d. "The reason for hospitalization is that complications could still occur." - ANSWER d.
"The reason for hospitalization is that complications could still occur."
, Why are infants particularly vulnerable to acceleration-deceleration head injuries?
a. The anterior fontanel is not yet closed.
b. The nervous tissue is not well developed.
c. The scalp of the head has extensive vascularity.
d. Musculoskeletal support of the head is insufficient. - ANSWER d. Musculoskeletal
support of the head is insufficient.
A child is brought to the emergency department after experiencing a seizure at school.
He has no history of seizures. The father tells the nurse that he cannot believe the child
has epilepsy. The nurse's best response is which of the following?
a. "Epilepsy is easily treated."
b. "Very few children have actual epilepsy."
c. "The seizure may or may not mean that your child has epilepsy."
d. "Your child has had only one convulsion; it probably won't happen again." - ANSWER
c. "The seizure may or may not mean that your child has epilepsy."
Which of the following is a clinical manifestation of increased intracranial pressure (ICP)
in infants?
a. Irritability
b. Photophobia
c. Vomiting and diarrhea
d. Pulsating anterior fontanel - ANSWER a. Irritability
The nurse is admitting a young child to the hospital because bacterial meningitis is
suspected. Which of the following is a priority of nursing care?
a. Initiate isolation precautions as soon as diagnosis is confirmed.
b. Provide environmental stimulation to keep the child awake.
c. Administer antibiotic therapy as soon as it is available.
d. Administer sedatives and analgesics on a preventive schedule to manage pain. -
ANSWER c. Administer antibiotic therapy as soon as it is available.
The nurse is caring for a 2-year-old girl who is unconscious but stable after a car
accident. Her parents are staying at the bedside most of the time. Which of the following
is an appropriate nursing intervention?
a. Suggest that the parents go home until she is alert enough to know they are present.
You are the nurse assigned to care for a child with a basilar skull fracture. Your most
important nursing observation is change in level of consciousness. You will be highly
alert for
a. Alterations in vital signs that often appear before alterations in consciousness or
focal neurologic signs
b. Bleeding from the ear, which is indicative of an anterior basal skull fracture
c. Seizures that are relatively uncommon in children at the time of head injury
d. Changes in posturing, such as any signs of extension or flexion posturing, unusual
response to stimuli, and random versus purposeful movement - ANSWER d. Changes in
posturing, such as any signs of extension or flexion posturing, unusual response to
stimuli, and random versus purposeful movement
As the nurse assigned to a child diagnosed with bacterial meningitis, you know that
a. The child will not need to be placed in isolation because antibiotics have been started
b. Enteric precautions will remain in place for up to 48 hours
c. Respiratory isolation will remain in place for 24 hours after antibiotics are started
d. Due to headache, the child will want the head of the bed elevated with 2 pillows -
ANSWER c. Respiratory isolation will remain in place for 24 hours after antibiotics are
started
You are working with a pediatric nurse who has just transferred to the pediatric clinic.
You are role playing phone triage related to a child with a head injury. You ascertain that
the nurse needs more teaching based on what response?
a. After initial physical exam, if there was no loss of consciousness with the head injury,
the can be observed at home
b. If there is a language barrier, written instructions can be given, followed by discharge
c. Another physical exam should take place in 1 or 2 days
d. Parents should call the doctor if their child has any of these signs: blurred vision,
walking unsteadily, or is hard to awaken - ANSWER b. If there is a language barrier,
written instructions can be given, followed by discharge
You are caring for a child with hydrocephalus who is postoperative from a shunt
revision. Which assessment findings is your priority for increased intracranial pressure
,a. Nausea and refusal to eat postoperatively
b. Complain of a headache
c. Irritability and wanting to sleep
d. Decrease in heart rate over the last hour - ANSWER d. Decrease in heart rate over the
last hour
You are working with a family that drouth their child into the pediatric clinic. The mother
describes what may be a type of seizure. What subjective data will help you determine
the type? SATA
a The presence or absence of an aura
b. If the child appeared disoriented after the seizure
c. Presence of vomiting after the seizure
d. The duration of the seizure
e. If the seizure was related to certain foods or occurred after a certain activity -
ANSWER a The presence or absence of an aura
b. If the child appeared disoriented after the seizure
d. The duration of the seizure
The Glasgow Coma Scale consists of an assessment of
a. pupil reactivity and motor response.
b. level of consciousness and verbal response.
c. eye opening and verbal and motor response.
d. intracranial pressure and level of consciousness. - ANSWER c. eye opening and
verbal and motor response.
A 3-year-old child is hospitalized after submersion injury. The child's mother complains
to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply
would be which of the following?
a. "He still needs a little extra oxygen."
b. "I'm sure he is fine, but the doctor wants to make sure."
c. "It is important to observe for possible physical reasons for the accident."
d. "The reason for hospitalization is that complications could still occur." - ANSWER d.
"The reason for hospitalization is that complications could still occur."
, Why are infants particularly vulnerable to acceleration-deceleration head injuries?
a. The anterior fontanel is not yet closed.
b. The nervous tissue is not well developed.
c. The scalp of the head has extensive vascularity.
d. Musculoskeletal support of the head is insufficient. - ANSWER d. Musculoskeletal
support of the head is insufficient.
A child is brought to the emergency department after experiencing a seizure at school.
He has no history of seizures. The father tells the nurse that he cannot believe the child
has epilepsy. The nurse's best response is which of the following?
a. "Epilepsy is easily treated."
b. "Very few children have actual epilepsy."
c. "The seizure may or may not mean that your child has epilepsy."
d. "Your child has had only one convulsion; it probably won't happen again." - ANSWER
c. "The seizure may or may not mean that your child has epilepsy."
Which of the following is a clinical manifestation of increased intracranial pressure (ICP)
in infants?
a. Irritability
b. Photophobia
c. Vomiting and diarrhea
d. Pulsating anterior fontanel - ANSWER a. Irritability
The nurse is admitting a young child to the hospital because bacterial meningitis is
suspected. Which of the following is a priority of nursing care?
a. Initiate isolation precautions as soon as diagnosis is confirmed.
b. Provide environmental stimulation to keep the child awake.
c. Administer antibiotic therapy as soon as it is available.
d. Administer sedatives and analgesics on a preventive schedule to manage pain. -
ANSWER c. Administer antibiotic therapy as soon as it is available.
The nurse is caring for a 2-year-old girl who is unconscious but stable after a car
accident. Her parents are staying at the bedside most of the time. Which of the following
is an appropriate nursing intervention?
a. Suggest that the parents go home until she is alert enough to know they are present.
