Pediatric HESI unit 4 Questions with
Answers
1.which intervention is a priority when caring for a child who sustained a
head injury 12 hours earlier?
a. assessing the level of consciousness every hour
b. promoting rest by fostering a quiet environment
c. asking about the circumstances that led to the injury
d. administering the prescribed opioid for complaints of a headache: a.
assess- ing the level of consciousness every hour
diminishing level of consciousness is an early indicator of neurological
damage, evidence of a subdural hemorrhage may take hours or days to
develop.
2.an 8 year old boy is found to have a mild concussion and is to be
discharged home. The parent is instructed to check their child for
responsiveness every 2 hours and to wake hi for this assessment after he
goes to sleep. They call the nurse and say they are afraid to allow him to go
to sleep. How would the nurse respond?
a. you can bring him to the hospital before bedtime, if you prefer
b. if your son becomes difficult to awaken bring him to the hospital.
c. theres no need to worry because you son is past the critical period.
d. awakening your son throughout the night is no longer necessary: b
3.a child is admitted to the pediatric intensive care unit with acute bacterial
meningitis. Which intervention would the nurse include in the plan of care?
a. offering clear liquids when the child is awake
b. checking the child level of consciousness hourly
c. assessing the childs BP every 4 hours
d. administering the prescribed oral antibiotic medication: b
checking LOC is part of the total neurological check, it can reveal
increasing ICP as result of cerebral inflammation.
4.Which clinical manifestation would the nurse recognize as a sign of neu-
rologic injury when assessing a 7 month old infant injured in an
automobile accident?
a. babinki reflex
b. persistent vomiting
c. heart rate of 110 bpm
d. temp of 99.6: b
,vomiting commonly accompanies a head injury because of increased ICP
5.which clinical finding would the nurse recognize as a sign that an
infants ICP has increased?
a. hypoactive reflexes
b. increased pulse rate
c. decreased BP
d. tension of anterior fontanel: d
anterior fontanel would be widened and tense due to increased volume o
cere- brospinal fluid
the pulse rate would be decreased
reflexes hyperactive
BP increased
6.which assessment finding alerts the nurse to suspect increasing ICP
in infant?
a. sunken eyes
b. projectile vomiting
c. depressed fonatanels
d. narrowing pulse pressure: b
increased ICP exerts pressure on the vomiting center in the brain
resulting in projective vomiting
7.which nursing care would the nurse provide for an infant the first 24
hours after surgical placement of a ventriculoperitoneal shunt for
hydrcephaus?
a. medicating the infant for pain
b. placing the infant in high fowlers
c. positioning the infant on the side that has the shunt
d. monitoring the infant for increasing ICP: d
shunt may become obstructed leading to accululation of CSF and
increased ICP
8.which symptoms would the nurse recognize as indicative of increased
ICP in 3 year old child? SATA
a. vomiting
b. headache
c. irritability
d. tachypnea
e. hypotension: a b c
9.which action would the nurse include in the plan of care for a 3 month
old infant with newly placed ventriculloperitoneal shunt?
a. keeping infant in prone
b. applying moist sterile dressing to incision
, c. watching for signs of CSF leakage
d. teaching parents signs of increased ICP: d
because condition may develop is shunt malfunction occurs
10.which clinical finding would indicate possible meningitis in an infant
with infected ventriculoperitoneal shunt? SATA
a. fever
b. lethargy
c. stiff neck
d. poor feeding
e. depressed fontanels: a b c d
11.a child who has undergone surgery to revise a ventriculoperitoneal
shunt is to be discharged. for which behavior would the nurse advise the
parent to call the clinic or seek immediate care?
a. appears drowsy after nap and becomes irritable
b. talks incessantly regardles of the presence of others
c. becomes angry when frustrated and has temper tantrum
d. starts arguments with playmates, claiming that the toys are theirs: a
drowsiness and irritability are characteristic of increased ICP along
with nausea, projectile vomiting, headache, and diminished physical
activity
12.which assessment finding would the nurse recognize as common in
in- fants with down syndrome?
a. bulging fontanels
b. stiff lower extremities
c. abnormal heart sounds
d. unusual pupillary reactions: c
cardiac anomalies often accompany genetic problems
13.a child with meningitis suddenly assumes an opisthotonic position.
In which position would the nurse position the child?
a. side lying
b. knee chest
c. high fowler
d. trendelenburg: a
maximal safety and comfort are ensured with the side lying position
because the child neck and back are hyperextended
14.which assessment finding would the nurse recognize as needing
interme- diate attention in a 2 week old infant?
a. tense anterior fontanel
b. uncoordinated eye/muscle movement
c. larger head circumference than chest circumference
Answers
1.which intervention is a priority when caring for a child who sustained a
head injury 12 hours earlier?
a. assessing the level of consciousness every hour
b. promoting rest by fostering a quiet environment
c. asking about the circumstances that led to the injury
d. administering the prescribed opioid for complaints of a headache: a.
assess- ing the level of consciousness every hour
diminishing level of consciousness is an early indicator of neurological
damage, evidence of a subdural hemorrhage may take hours or days to
develop.
2.an 8 year old boy is found to have a mild concussion and is to be
discharged home. The parent is instructed to check their child for
responsiveness every 2 hours and to wake hi for this assessment after he
goes to sleep. They call the nurse and say they are afraid to allow him to go
to sleep. How would the nurse respond?
a. you can bring him to the hospital before bedtime, if you prefer
b. if your son becomes difficult to awaken bring him to the hospital.
c. theres no need to worry because you son is past the critical period.
d. awakening your son throughout the night is no longer necessary: b
3.a child is admitted to the pediatric intensive care unit with acute bacterial
meningitis. Which intervention would the nurse include in the plan of care?
a. offering clear liquids when the child is awake
b. checking the child level of consciousness hourly
c. assessing the childs BP every 4 hours
d. administering the prescribed oral antibiotic medication: b
checking LOC is part of the total neurological check, it can reveal
increasing ICP as result of cerebral inflammation.
4.Which clinical manifestation would the nurse recognize as a sign of neu-
rologic injury when assessing a 7 month old infant injured in an
automobile accident?
a. babinki reflex
b. persistent vomiting
c. heart rate of 110 bpm
d. temp of 99.6: b
,vomiting commonly accompanies a head injury because of increased ICP
5.which clinical finding would the nurse recognize as a sign that an
infants ICP has increased?
a. hypoactive reflexes
b. increased pulse rate
c. decreased BP
d. tension of anterior fontanel: d
anterior fontanel would be widened and tense due to increased volume o
cere- brospinal fluid
the pulse rate would be decreased
reflexes hyperactive
BP increased
6.which assessment finding alerts the nurse to suspect increasing ICP
in infant?
a. sunken eyes
b. projectile vomiting
c. depressed fonatanels
d. narrowing pulse pressure: b
increased ICP exerts pressure on the vomiting center in the brain
resulting in projective vomiting
7.which nursing care would the nurse provide for an infant the first 24
hours after surgical placement of a ventriculoperitoneal shunt for
hydrcephaus?
a. medicating the infant for pain
b. placing the infant in high fowlers
c. positioning the infant on the side that has the shunt
d. monitoring the infant for increasing ICP: d
shunt may become obstructed leading to accululation of CSF and
increased ICP
8.which symptoms would the nurse recognize as indicative of increased
ICP in 3 year old child? SATA
a. vomiting
b. headache
c. irritability
d. tachypnea
e. hypotension: a b c
9.which action would the nurse include in the plan of care for a 3 month
old infant with newly placed ventriculloperitoneal shunt?
a. keeping infant in prone
b. applying moist sterile dressing to incision
, c. watching for signs of CSF leakage
d. teaching parents signs of increased ICP: d
because condition may develop is shunt malfunction occurs
10.which clinical finding would indicate possible meningitis in an infant
with infected ventriculoperitoneal shunt? SATA
a. fever
b. lethargy
c. stiff neck
d. poor feeding
e. depressed fontanels: a b c d
11.a child who has undergone surgery to revise a ventriculoperitoneal
shunt is to be discharged. for which behavior would the nurse advise the
parent to call the clinic or seek immediate care?
a. appears drowsy after nap and becomes irritable
b. talks incessantly regardles of the presence of others
c. becomes angry when frustrated and has temper tantrum
d. starts arguments with playmates, claiming that the toys are theirs: a
drowsiness and irritability are characteristic of increased ICP along
with nausea, projectile vomiting, headache, and diminished physical
activity
12.which assessment finding would the nurse recognize as common in
in- fants with down syndrome?
a. bulging fontanels
b. stiff lower extremities
c. abnormal heart sounds
d. unusual pupillary reactions: c
cardiac anomalies often accompany genetic problems
13.a child with meningitis suddenly assumes an opisthotonic position.
In which position would the nurse position the child?
a. side lying
b. knee chest
c. high fowler
d. trendelenburg: a
maximal safety and comfort are ensured with the side lying position
because the child neck and back are hyperextended
14.which assessment finding would the nurse recognize as needing
interme- diate attention in a 2 week old infant?
a. tense anterior fontanel
b. uncoordinated eye/muscle movement
c. larger head circumference than chest circumference
