Peds: Final Exam Test Bank graded A
1) Which assessment finding for a 4-month-old infant would require further action by the
nurse?
1. The posterior fontanel is open.
2. The infant has good head control when held upright.
3. The infant is able to roll only from abdomen to back.
4. The anterior fontanel is open and soft. - correct answer1. The posterior fontanel is
open.
2) The nurse is providing care for a pediatric client in the emergency department (ED)
with a diagnosis of decreased level of consciousness (LOC) secondary to increased
intracranial pressure (ICP). Which healthcare provider order should the nurse question?
1. Passive range-of-motion exercises to promote hip flexion
2. Oxygen at 2 L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neurologic checks
4. Elevate head of bed 30 degrees - correct answer1. Passive range-of-motion
exercises to promote hip flexion
3) A 4-year-old client with intractable seizures has been on a ketogenic diet for the last
6 months, with a decrease in seizure activity. This child is now admitted to the pediatric
unit with left-sided pain. Which possible complication to this diet does the nurse
suspect?
1. Appendicitis
2. Bowel obstruction
3. Urinary tract infection
4. Kidney stones - correct answer4. Kidney stones
4) A child with a history of seizures arrives in the emergency department (ED) in status
epilepticus. Which is the priority nursing action?
1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurologic assessment.
4. Maintain patent airway. - correct answer4. Maintain patent airway.
5) The nurse is teaching a mother of a young child with a newly diagnosed seizure
disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which
parental statement indicates the need for further education?
1. "I will not use carbonated beverages to dilute his medication."
2. "I will give his medicine on an empty stomach so he will absorb it better."
3. "I will not let him chew his tablet."
,Peds: Final Exam Test Bank graded A
4. "I will bring him to the physician's office for regular blood work to check bleeding
times." - correct answer2. "I will give his medicine on an empty stomach so he will
absorb it better."
6) A young child admitted to the pediatric unit has fever, irritability, and vomiting with
suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse
anticipate based on these data?
1. Decreased protein count
2. Clear, straw-colored fluid
3. Positive for red blood cells (RBCs)
4. Decreased glucose level - correct answer4. Decreased glucose level
7) Which is the priority nursing diagnosis when planning care for a pediatric client who is
diagnosed with bacterial meningitis?
1. Impaired Gas Exchange
2. Risk for Infection
3. Anxiety (parental)
4. Acute Pain - correct answer1. Impaired Gas Exchange
8) The nurse is caring for a 9-month-old infant who just returned from the
postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which
healthcare provider prescription should the nurse question?
1. Vital signs and neurologic checks hourly
2. Small, frequent formula feedings
3. Elevate head of bed
4. Daily head circumference - correct answer3. Elevate head of bed
9) A neonate with a meningomyelocele is to have surgery in the morning. Which nursing
action is appropriate for this neonate?
1. Applying a diaper to prevent contamination of sac
2. Positioning the newborn in a side-lying position
3. Encouraging the mother to hold the newborn because she will not be able to pick him
up after surgery
4. Positioning the newborn in a prone position - correct answer4. Positioning the
newborn in a prone position
10) Which should the nurse include in the plan of care for a hospitalized school-age
child with meningomyelocele? Select all that apply.
1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
, Peds: Final Exam Test Bank graded A
4. Ensuring that the client has a low-fiber diet
5. Encouraging the client to shift positions hourly when in the wheelchair - correct
answer1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
5. Encouraging the client to shift positions hourly when in the wheelchair
11) Which side effect should the nurse include in the parent teaching for a child who is
prescribed a baclofen pump for cerebral palsy?
1. Diarrhea
2. Hypertonia
3. Hypotonia
4. Restlessness - correct answer3. Hypotonia
12) A 9-month-old infant who is not sitting independently has been diagnosed with
ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see
in the baby?
1. Hypotonia and muscle instability
2. Hypertonia and persistence primitive reflexes
3. Tremors and exaggerated posturing
4. Hemiplegia and hypertonia - correct answer1. Hypotonia and muscle instability
13) A pediatric client is admitted to the emergency department with a traumatic brain
injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart
rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. Which
does the nurse suspect based on these data?
1. Spinal cord injury
2. Increased intracranial pressure.
3. Typical for sleep
4. Improvement - correct answer2. Increased intracranial pressure.
14) Which clinical manifestation should the nurse monitor for when assessing a
pediatric client who is diagnosed with a basilar skull fracture?
1. Periorbital ecchymosis
2. Subdural hematoma
3. Protruding bone
4. Epidural hematoma - correct answer1. Periorbital ecchymosis
15) A teacher states to the school nurse, "I have a student who will often just stare at
me for 15 seconds after asking a question; then the student blinks and asks me to
repeat the question. Should I be concerned?" Which should the nurse include in the
response to the teacher?
1) Which assessment finding for a 4-month-old infant would require further action by the
nurse?
1. The posterior fontanel is open.
2. The infant has good head control when held upright.
3. The infant is able to roll only from abdomen to back.
4. The anterior fontanel is open and soft. - correct answer1. The posterior fontanel is
open.
2) The nurse is providing care for a pediatric client in the emergency department (ED)
with a diagnosis of decreased level of consciousness (LOC) secondary to increased
intracranial pressure (ICP). Which healthcare provider order should the nurse question?
1. Passive range-of-motion exercises to promote hip flexion
2. Oxygen at 2 L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neurologic checks
4. Elevate head of bed 30 degrees - correct answer1. Passive range-of-motion
exercises to promote hip flexion
3) A 4-year-old client with intractable seizures has been on a ketogenic diet for the last
6 months, with a decrease in seizure activity. This child is now admitted to the pediatric
unit with left-sided pain. Which possible complication to this diet does the nurse
suspect?
1. Appendicitis
2. Bowel obstruction
3. Urinary tract infection
4. Kidney stones - correct answer4. Kidney stones
4) A child with a history of seizures arrives in the emergency department (ED) in status
epilepticus. Which is the priority nursing action?
1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurologic assessment.
4. Maintain patent airway. - correct answer4. Maintain patent airway.
5) The nurse is teaching a mother of a young child with a newly diagnosed seizure
disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which
parental statement indicates the need for further education?
1. "I will not use carbonated beverages to dilute his medication."
2. "I will give his medicine on an empty stomach so he will absorb it better."
3. "I will not let him chew his tablet."
,Peds: Final Exam Test Bank graded A
4. "I will bring him to the physician's office for regular blood work to check bleeding
times." - correct answer2. "I will give his medicine on an empty stomach so he will
absorb it better."
6) A young child admitted to the pediatric unit has fever, irritability, and vomiting with
suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse
anticipate based on these data?
1. Decreased protein count
2. Clear, straw-colored fluid
3. Positive for red blood cells (RBCs)
4. Decreased glucose level - correct answer4. Decreased glucose level
7) Which is the priority nursing diagnosis when planning care for a pediatric client who is
diagnosed with bacterial meningitis?
1. Impaired Gas Exchange
2. Risk for Infection
3. Anxiety (parental)
4. Acute Pain - correct answer1. Impaired Gas Exchange
8) The nurse is caring for a 9-month-old infant who just returned from the
postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which
healthcare provider prescription should the nurse question?
1. Vital signs and neurologic checks hourly
2. Small, frequent formula feedings
3. Elevate head of bed
4. Daily head circumference - correct answer3. Elevate head of bed
9) A neonate with a meningomyelocele is to have surgery in the morning. Which nursing
action is appropriate for this neonate?
1. Applying a diaper to prevent contamination of sac
2. Positioning the newborn in a side-lying position
3. Encouraging the mother to hold the newborn because she will not be able to pick him
up after surgery
4. Positioning the newborn in a prone position - correct answer4. Positioning the
newborn in a prone position
10) Which should the nurse include in the plan of care for a hospitalized school-age
child with meningomyelocele? Select all that apply.
1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
, Peds: Final Exam Test Bank graded A
4. Ensuring that the client has a low-fiber diet
5. Encouraging the client to shift positions hourly when in the wheelchair - correct
answer1. Implementing interventions for a client of normal intelligence
2. Using latex precautions when providing client care
3. Allowing the client to self-catheterize
5. Encouraging the client to shift positions hourly when in the wheelchair
11) Which side effect should the nurse include in the parent teaching for a child who is
prescribed a baclofen pump for cerebral palsy?
1. Diarrhea
2. Hypertonia
3. Hypotonia
4. Restlessness - correct answer3. Hypotonia
12) A 9-month-old infant who is not sitting independently has been diagnosed with
ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see
in the baby?
1. Hypotonia and muscle instability
2. Hypertonia and persistence primitive reflexes
3. Tremors and exaggerated posturing
4. Hemiplegia and hypertonia - correct answer1. Hypotonia and muscle instability
13) A pediatric client is admitted to the emergency department with a traumatic brain
injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart
rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. Which
does the nurse suspect based on these data?
1. Spinal cord injury
2. Increased intracranial pressure.
3. Typical for sleep
4. Improvement - correct answer2. Increased intracranial pressure.
14) Which clinical manifestation should the nurse monitor for when assessing a
pediatric client who is diagnosed with a basilar skull fracture?
1. Periorbital ecchymosis
2. Subdural hematoma
3. Protruding bone
4. Epidural hematoma - correct answer1. Periorbital ecchymosis
15) A teacher states to the school nurse, "I have a student who will often just stare at
me for 15 seconds after asking a question; then the student blinks and asks me to
repeat the question. Should I be concerned?" Which should the nurse include in the
response to the teacher?
