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Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 1 of 25
1. A preschooler has a small laceration that required 2 stitches. The nurse covers the wound
with a bandage knowing that it will comfort the child to have it covered. What is the
developmental reason for this intervention?
A. Preschoolers are magical thinkers and imagine bandages keep their insides
from coming out
Rationale: Preschoolers are magical and illogical thinkers and have
difficulty distinguishing fantasy from reality. They have
misconceptions about illness, injury, and bodily functions. For
example, they perceive that if their skin is cut, they fear their insides
will leak out. Covering a wound with a bandage helps them with this
fear (p. 37).
B. Preschoolers fear physical disability and believe a bandage will prevent disability
Rationale: School-aged children fear physical disability and are not
necessarily reassured by a bandage (p. 37).
C. Preschoolers explore orally and will likely chew or suck on the stitches if left
uncovered
Rationale: Infants, not preschoolers, are oral explorers. All objects are
brought to the mouth and the infant would be likely to chew or suck on the
stitches (p. 34–35).
D. Preschoolers are concerned with body image and don’t want to appear different
than peers
Rationale: Preschoolers are concerned with body disfigurement and
mutilation in a magical thinking, imaginary way. Body image and peer
acceptance are characteristics of adolescents (p. 39–40).
Chapter 3 From the Start
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 2 of 25
2. A 7-month-old presents to the emergency department with a complaint of fever.
Assessment reveals a patent airway and slight cyanosis around his lips and nail beds. He
is alert and interactive. His vital signs are 38.5 °C (101.3 °F), HR 134, RR 32, BP 78/54
mm Hg, and SpO2 84%. The nurse notes a healed surgical scar on his chest. Based on this
assessment, what is the nurse’s priority?
A. Administer ibuprofen to treat the fever
Rationale: Children with special health care needs may present differently
than other children, and although he likely has a history of surgical heart
repair, an oxygen saturation of 84% is not normal for most children, so it
cannot be ignored until a baseline status is obtained from the caregiver. If
it is not normal for him, oxygen must be applied before treating the fever
(p. 68).
B. Begin oxygen via a nonrebreather mask
Rationale: Children with special health care needs may present differently
than other children, but these differences may be normal. The surgical scar
on the chest is likely from a congenital heart defect repair. Until it is
verified that his baseline status includes a lower oxygen saturation and
cyanosis, oxygen should not be applied. In some cases of congenital heart
disease, added oxygen is detrimental (p. 68).
C. Obtain a surgical history
Rationale: Children with special health care needs may present differently
than other children, and although he likely has a history of surgical heart
repair, an oxygen saturation of 84% is not normal for most children.
Therefore, it cannot be ignored until a baseline status is obtained from the
caregiver. A surgical history may be lengthy and details should wait until
the child is stabilized (p. 68).
D. Ask if the SpO2 is normal for him
Rationale: Children with special health care needs may present
differently than other children, but these differences may be normal.
The surgical scar on the chest is likely from a congenital heart defect
repair. The mother’s chief complaint is the fever, not the color, pulse
oximetry, or the respiratory distress. This may be because these
aspects of his assessment are normal. The intact mental status is also a
sign that he has adapted to lowered oxygen saturations. The child’s
baseline must come from the caregiver before any intervention (p. 68).
Chapter 3 From the Start
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 3 of 25
3. An 11-year-old presents to the emergency department with a complaint of hitting his
head while playing soccer. The nurse enters the room and performs an across-the-room
assessment. He is staring at the wall. He has no increased work of breathing, and his
color is pink. Using the pediatric assessment triangle (PAT), what classification will the
nurse assign?
A. Well
Rationale: In using the PAT, there is not a Well category. A child may
appear well and without disruption in any of the three components of the
PAT but is still designated sick. All pediatric patients presenting to the
emergency department are considered sick simply based on the fact that
the caregiver was concerned enough to bring the child to the emergency
department (p. 54).
B. Sick
Rationale: If there is no disruption in any of the three components of the
PAT, a pediatric patient is considered sick. This child has an abnormality
in one of the three. He is staring at the wall, which is a disruption in the
general appearance component (p. 54).
C. Sicker
Rationale: This child has a disruption in one of the three components
of the PAT. He is staring at the wall, which is a disruption in the
general appearance component. It may be that he is anxious and
fearful about the experience, but it could be a result of the head
injury. More assessment is required (p. 54). D. Sickest
Rationale: If there are disruptions in two or more of the three component
of the PAT, a pediatric patient is considered sickest and needs immediate
evaluation and intervention. This child has an abnormality in one of the
three components (p. 54).
Chapter 4 Prioritization: Focused Assessment, Triage, and Decision Making
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 4 of 25
4. The pediatric prioritization process components include the focused assessment, focused
history, acuity rating decision and:
A. the pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization process
include the pediatric assessment triangle (PAT), the focused
assessment (objective data), the focused history (subjective data), and
the assignment of the triage acuity rating. These components ensure
enough information is rapidly gathered and used to provide
appropriate care and timely interventions for pediatric patients (p.
52). B. developmental characteristics.
Rationale: Developmental characteristics are incorporated into each
component of the pediatric prioritization process but do not constitute a
separate element (p. 52).
C. head-to-toe assessment.
Rationale: The head-to-toe assessment is part of the focused assessment
but not a separate element (p. 52).
D. life-saving interventions.
Rationale: Life-saving interventions should be performed at any point
throughout the prioritization process as life threats are identified (p. 52).
Chapter 4 Prioritization: Focused Assessment, Triage, and Decision Making
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 5 of 25
5. A 2-year-old is brought to the emergency department by her father when he found her
face down in the pool. She remains unresponsive and is breathing shallowly and slowly.
Her color is pale. What is the priority?
A. Administer 100% oxygen
Rationale: The primary assessment in a trauma patient begins with
immobilization of the cervical spine while opening the airway. The
remainder of the primary assessment interventions including oxygenation
is performed after cervical spinal immobilization (p. 64).
B. Immobilize the cervical spine
Rationale: Any unresponsive child found in a pool must be assumed to
be a trauma patient and with a cervical spinal injury until proven
otherwise. The primary assessment in a trauma patient begins with
immobilization of the cervical spine while opening the airway. The
remainder of the primary assessment interventions including
inserting an airway, oxygenation, and ventilation, is performed after
cervical spinal immobilization (p. 64).
C. Begin bag-mask ventilation
Rationale: The primary assessment in a trauma patient begins with
immobilization of the cervical spine while opening the airway. The
remainder of the primary assessment interventions including ventilation is
performed after cervical spinal immobilization (p. 64).
D. Insert an oral airway
Rationale: The primary assessment in a trauma patient begins with
immobilization of the cervical spine while opening the airway. The
remainder of the primary assessment interventions including inserting an
airway, if needed, is performed after cervical spinal immobilization (p.
64).
Chapter 5 Initial Assessment
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 6 of 25
6. A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal
alignment, padding should be placed under which area?
A. Shoulders
Rationale: The younger child has a larger head proportionally to the
body and when lying supine is naturally in a position of cervical
flexion. Padding under the shoulders or upper torso will bring the
cervical spine into neutral alignment. The shoulder should be
horizontally aligned with the external auditory meatus (p. 64).
B. Head
Rationale: Padding under the head will exacerbate this flexion (p. 64).
C. Neck
Rationale: Padding under the neck will not correct the anatomic flexion (p.
64).
D. Waist
Rationale: Padding under the waist will not affect the cervical spinal
alignment (p. 64).
Chapter 5 Initial Assessment
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 7 of 25
7. The nurse is preparing to administer a feeding through a nasogastric feeding tube. The
tube position was verified by radiograph after insertion 2 hours ago. How will the nurse
verify placement before feeding?
A. Instill air and listen over the epigastrium
Rationale: The research regarding verification of gastric or feeding tube
placement has demonstrated that the standard method of instillation of air
and auscultation over the epigastrium for gurgling has been associated
with improper placement and adverse outcomes (p. 103).
B. Test the pH of the gastric contents
Rationale: The research regarding verification of gastric or feeding
tube placement has demonstrated that the standard method of
instillation of air and auscultation over the epigastrium for gurgling
has been associated with improper placement and adverse outcomes.
The use of pH testing had been demonstrated to be safer and has been
adopted as policy in many institutions (p. 103) C. Observe color of a gastric aspirate sample.
Rationale: Aspiration of gastric contents is done to perform pH testing, not
observation of color (p. 103).
D. Repeat the radiograph
Rationale: Verification of placement by radiograph is generally done
initially, but subsequent verifications are better established by pH testing
(p. 103).
Chapter 7 Common Procedures and Sedation
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 8 of 25
8. What is the best method to rapidly administer a 20 mL/kg bolus of 0.9% normal saline to
a pediatric patient weighing 16 kg?
A. A 20-mL syringe with a stopcock
Rationale: With a 20-mL syringe and a three-way stopcock, the nurse
can quickly deliver an appropriate bolus of 0.9% normal saline by
drawing up and administering 20 mL once for each kilogram of the
pediatric patient’s weight or 16 times for this patient.
B. An infusion pump
Rationale: An infusion pump is a good solution, but it will take longer
than the method using a 20-mL syringe and a stopcock. Most infusion
pumps have an upper limit of 999 mL/hour; delivering the required 320
mL for this patient will take nearly 20 minutes.
C. A rapid infuser
Rationale: Rapid infuser devices are used on patients weighing at least 25
kg and receiving a minimum of 500 mL. This patient does not meet either
requirement for use.
D. A pressure bag
Rationale: A pressure bag is sometimes quite useful in administering a
large amount of fluid; however the higher pressures generated may result
in venous rupture in younger children.
Chapter 8 Medication Administration
Pediatric Clinical Considerations: Medication Administration and
Vascular Access
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 9 of 25
9. Immediately after intraosseous insertion the nurse assesses the infusion and notes that the
fluid is not dripping. How should the nurse respond?
A. Use an infusion pump to deliver the fluids
Rationale: Fluids infusing through an intraosseous device do not
necessarily run by gravity. The use of an infusion pump is usually
required (p. 127).
B. Remove the device and insert in another site
Rationale: Fluids infusing through an intraosseous device do not necessarily
run by gravity. This does not mean it is nonfunctional and removal is not
indicated (p. 127).
C. Advance the device and reassess the flow
Rationale: Advancing the device if it is currently correctly placed may
penetrate the far wall of the bone and produce infiltration (p. 127).
D. Attempt to aspirate bone marrow
Rationale: Aspiration of bone marrow confirms correct placement of an
intraosseous device, but lack of return is not a sign of incorrect placement.
Bone marrow aspiration is not always possible in some severely dehydrated
pediatric patients (p. 127).
Chapter 9 Vascular Access
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 10 of 25
10. A 13-month-old presents to the emergency department with a 2-day history of a low-
grade fever, increased work of breathing, and tonight developed a barking cough and
inspiratory stridor. What condition does the nurse suspect?
A. Epiglottitis
Rationale: Epiglottitis has a sudden onset of high fever, sore throat,
difficulty swallowing, and muffled voice and quickly progresses to
drooling, tripod positioning, and stridor (p. 137).
B. Foreign body aspiration
Rationale: This patient is the right age for a foreign body aspiration as it is
more common in infants and toddlers who explore the world orally, but
the gradual onset, low-grade fever, and barking cough indicates an
infectious process, specifically croup (p. 137).
C. Tracheomalacia
Rationale: Tracheomalacia is a chronic condition affecting the upper
airway that may be an indication for a tracheostomy, but it is not acute,
nor associated with infectious processes (p. 136, 142–143).
D. Croup
Rationale: Croup is most commonly seen in children between the ages
of 6 and 36 months and has a gradual onset of cold symptoms
including a low-grade fever, tachypnea, tachycardia, retractions, and
inspiratory stridor. The classic sign is a barking cough that worsens at
night (p. 137).
Chapter 10 Respiratory Emergencies
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 11 of 25
11. In providing education to a family regarding obtaining baseline peak airway flow for a
child with asthma, the nurse will recommend what time of day?
A. At bedtime
Rationale: The recommended time to obtain baseline peak flow readings is
first thing in the morning before any administration of bronchodilator
therapy (p. 138, 140).
B. Before exercise
Rationale: The recommended time to obtain baseline peak flow readings is
first thing in the morning before any administration of bronchodilator
therapy (p. 138, 140).
C. In the morning
Rationale: The recommended time to obtain baseline peak flow
readings is first thing in the morning before any administration of
bronchodilator therapy (p. 138, 140).
D. After meals
Rationale: The recommended time to obtain baseline peak flow readings is
first thing in the morning before any administration of bronchodilator
therapy (p. 138, 140).
Chapter 10 Respiratory Emergencies
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 12 of 25
12. The nurse is planning to begin oral rehydration therapy for a 9-month-old with mild
dehydration. She provides the caregivers with a glucose and sodium solution and
instructs them to administer small amounts:
A. Every 2 to 5 minutes
Rationale: Oral rehydration should be attempted in those pediatric
patients who can tolerate oral fluids with mild dehydration. Frequent
(every 2 to 5 minutes), small sips of a commercially prepared glucose
and sodium solution, such as Pedialyte or Infalyte, is the most
successful method (p. 149).
B. Every 10 to 12 minutes
Rationale: Oral rehydration should be attempted in those pediatric patients
who can tolerate oral fluids with mild dehydration. Frequent, small sips of
a commercially prepared glucose and sodium solution, such as Pedialyte
or Infalyte, is the most successful method (p. 149).
C. Every 15 minutes
Rationale: Oral rehydration should be attempted in those pediatric patients
who can tolerate oral fluids with mild dehydration. Frequent, small sips of
a commercially prepared glucose and sodium solution, such as Pedialyte
or Infalyte, is the most successful method (p. 149).
D. Every 30 minutes
Rationale: Oral rehydration should be attempted in those pediatric patients
who can tolerate oral fluids with mild dehydration. Frequent, small sips of
a commercially prepared glucose and sodium solution, such as Pedialyte
or Infalyte, is the most successful method (p. 149).
Chapter 11 Childhood Illness
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 13 of 25
13. Caregivers bring in their 3-week-old neonate and describe nonbilious vomiting after
every feeding that is becoming more forceful over the past 24 hours. The last time he
vomited the vomitus hit a chair 2 feet away. They say he cries, roots, and sucks
vigorously on his pacifier right after vomiting as though still hungry. He is not
experiencing any diarrhea. What condition is the most likely cause of these signs and
symptoms?
A. Intussusception
Rationale: Intussusception occurs most commonly in males aged 3 to 12
months and manifests with episodic abdominal pain, drawing up of the
legs, and vomiting. It is not associated with projectile vomiting (p. 155)
B. Volvulus
Rationale: Volvulus presents with bilious vomiting, and not projectile. (p.
156).
C. Gastroenteritis
Rationale: Gastroenteritis does present with vomiting but usually includes
diarrhea and the vomiting is usually not projectile as seen in pyloric
stenosis (p. 151).
D. Pyloric stenosis
Rationale: Pyloric stenosis is the narrowing of the pylorus, the
opening from the stomach into the small intestine. It is most
commonly seen in males between 2 and 8 weeks of age. They present
with nonbilious vomiting, usually after every feeding, that becomes
projectile as the obstruction worsens. With pyloric stenosis the infant
remains constantly hungry and will demonstrate hunger behaviors
after vomiting. If the diagnosis is delayed, dehydration and signs of
hypovolemia may occur (p. 155).
Chapter 11 Childhood Illness
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 14 of 25
14. A neonate is delivered in the emergency department and placed on a radiant warmer.
There is no staining of the amniotic fluid. What is the first step in neonatal resuscitation?
A. Dry and warm the neonate
Rationale: The steps in neonatal resuscitation are 1) dry and warm
the patient, 2) maintain airway patency, 3) maintain breathing
effectiveness, 4) maintain adequate circulation, 5) obtain vascular
access, 6) administer medications, 7) intervene if positive pressure
ventilation fails, and 8) volume expansion and vasopressor support. At
each step, the neonate is assessed to determine response to care. If the
response is absent or inadequate, the steps become more invasive and
complex (p. 187–189).
B. Suction the mouth and nose
Rationale: The steps in neonatal resuscitation are 1) dry and warm the
patient, 2) maintain airway patency, which begins with positioning to open
the airway, and suctioning the mouth first and then the nose with a bulb
syringe, maintain breathing effectiveness, 4) maintain adequate
circulation, 5) obtain vascular access, 6) administer medications, 7)
intervene if positive pressure ventilation fails, and 8) volume expansion
and vasopressor support. At each step, the neonate is assessed to
determine response to care. If the response is absent or inadequate, the
steps become more invasive and complex (p. 187–189).
C. Assess for effective breathing
Rationale: The steps in neonatal resuscitation are 1) dry and warm the
patient, 2) maintain airway patency, 3) maintain breathing effectiveness,
which begins with gentle tactile stimulation, then blended oxygen,
positive-pressure ventilation and intubation as needed, 4) maintain
adequate circulation, 5) obtain vascular access, 6) administer medications,
7) intervene if positive pressure ventilation fails, and 8) volume expansion
and vasopressor support. At each step, the neonate is assessed to
determine response to care. If the response is absent or inadequate, the
steps become more invasive and complex (p. 187–189).
D. Palpate a central pulse rate
Rationale: The steps in neonatal resuscitation are 1) dry and warm the
patient, 2) maintain airway patency, 3) maintain breathing effectiveness,
4) maintain adequate circulation, which begins with palpating a central
pulse, either at the brachial artery or base of the umbilicus and cardiac
compressions as needed, 5) obtain vascular access, 6) administer
medications, 7) intervene if positive pressure ventilation fails, and 8)
volume expansion and vasopressor support. At each step, the neonate is
assessed to determine response to care. If the response is absent or
inadequate, the steps become more invasive and complex (p. 187–189).
Chapter 12 The Neonate
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 15 of 25
15. In discussing the legal care of the adolescent patient, what is a mature minor?
A. A minor who lives independently and is legally able to make health decisions
Rationale: An emancipated minor is a minor who has been legally
declared independent of his or her parent or guardian. Some examples are
minors who are married, serve in the military, or are living independently
from parents. These minors are considered an adult for health care
decisions (p. 204).
B. A minor who is able to make decisions regarding his or her own sexual or mental
health
Rationale: In most jurisdictions, adolescents are allowed to make decisions
regarding specific health services, including reproductive health,
pregnancy-related care, sexual health, drug and alcohol treatment, and
mental health (p. 204–205).
C. A minor who is able to make decisions regarding health care as a parent of his or
her own child
Rationale: A minor who is a parent is generally considered an
emancipated minor and is able to make decisions regarding his or her
child’s health (p. 204).
D. A minor who lives with a parent or guardian but legally is able to make
health decisions
Rationale: A mature minor remains in the care and supervision of his
or her parent or guardian but has been granted legal permission to
make independent health care decisions. The adolescent must be able
to understand the risks and benefits of possible treatments. This
definition may vary by state or jurisdiction. Know your own local
legal definitions (p. 204).
Chapter 13 The Adolescent
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 16 of 25
16. Which of the following screening statements/questions is most appropriate in assessing
an adolescent for dating violence?
A. “What triggers violence you’ve experienced from your partner?”
Rationale: Asking about triggers for violence may be interpreted as the
victim doing something to cause the violence and he or she may wish to
defend the relationship. This is especially true if the partner has isolated
him or her from friends and family or if the victim already feels shame or
guilt (p. 214–215).
B. “Does your partner feel entitled to sex even if you say ‘no’?”
Rationale: It may be difficult and unhelpful to ask the adolescent to
answer from the perspective of the dating partner (p. 215).
C. “Tell me about a time when you’ve felt unsafe in your relationship.”
Rationale: Dating violence in the adolescent population requires
screening as intimate partner violence is screened in the adult
population. Screening should include directive and probing questions
to discover violence in a dating relationship. Asking the adolescent to
relate a time he or she felt unsafe will help the nurse assess for
violence without the accusations or judgment (p. 215).
D. “Do you feel if you tried harder to please, your partner will not become violent?”
Rationale: Victims of dating violence may feel that if they tried harder,
their partners may be less violent, but this is a myth that should not be
perpetuated (p. 215).
Chapter 13 The Adolescent
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 17 of 25
17. Which sign distinguishes compensated shock from decompensated shock in the pediatric
patient?
A. Peripheral pulses
Rationale: Compensatory mechanisms in the pediatric patient are systemic
responses to the shock state to prevent hypotension and cardiovascular
collapse. These mechanisms include peripheral vasoconstriction to shunt
blood to vital organs, which manifests as weakening pulses, delayed
capillary refill, and cool, mottled skin (p. 231–232, 237).
B. Blood pressure
Rationale: Decompensated shock, also referred to as hypovolemic
shock, occurs when the compensatory mechanisms in the pediatric
patient, including increasing cardiac output with tachycardia and
peripheral vasoconstriction to shunt blood to vital organs, which
manifests as weakening pulses, delayed capillary refill, and cool,
mottled skin. In pediatric patients, it is at this point that blood
pressure drops and decompensated shock occurs (p. 229, 231).
C. Capillary refill
Rationale: Compensatory mechanisms in the pediatric patient are systemic
responses to the shock state to prevent hypotension and cardiovascular
collapse. These mechanisms include peripheral vasoconstriction to shunt
blood to vital organs, which manifests as weakening pulses, delayed
capillary refill, and cool, mottled skin (p. 229, 231).
D. Level of consciousness
Rationale: Changes in level of consciousness occur as cerebral perfusion
drops. The signs include anxiety, irritability, restlessness, and lethargy,
progressing to unresponsiveness and coma. As loss of consciousness
develops, decompensation may be imminent, but the definition of
decompensated shock is the onset of hypotension (p. 229, 230).
Chapter 14 Shock
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 18 of 25
18. A 5-year-old arrives to the emergency department unconscious with a heart rate of 32
beats/minute, weak, thready pulses, and pale, mottled skin. The team has begun bag-mask
ventilation with 100% oxygen and chest compressions with no improvement in the heart
rate. An intraosseous line is in place. Which of the following interventions is the priority?
A. Administration of atropine
Rationale: Atropine is only indicated in pediatric bradycardia if it is the
result of vagal nerve stimulation. If the history does not indicate a reason
for vagal stimulation, such as vigorous suctioning, the medication of
choice is epinephrine (p. 251).
B. Transcutaneous pacing
Rationale: Transcutaneous pacing may be necessary if there is no response
to epinephrine, but it should be given first (p. 251).
C. Administration of epinephrine
Rationale: For symptomatic bradycardia in the pediatric population
begin with oxygenation and ventilation. If those interventions do not
raise the heart rate, the next step is epinephrine, which will increase
peripheral vascular resistance and provide improved blood flow to
vital organs and increase heart rate and contractility (p. 250–251).
D. Attempt vagal stimulation
Rationale: Vagal stimulation is an intervention for supraventricular
tachycardia, not bradycardia (p. 253).
Chapter 15 Rhythm Disturbances
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 19 of 25
19. A 9-month-old infant pulled himself up onto the hearth of a fireplace. While doing so, he
fell forward onto the hot glass doors and sustained deep partial thickness burns to the
bilateral palmar aspects of both hands. What is the approximate percentage of total body
surface area burned?
A. 1%
Rationale: An estimation of the burn area can be performed by assuming
each palmar surface of the patient’s hand represents approximately 1% of
the total body surface area. (p. 273).
B. 2%
Rationale: An estimation of the burn area can be performed by
assuming each palmar surface of the patient’s hand represents
approximately 1% of the total body surface area. In this case, both
hands equal 2% (p. 273).
C. 4%
Rationale: An estimation of the burn area can be performed by assuming
each palmar surface of the patient’s hand represents approximately 1% of
the total body surface area. (p. 273).
D. 5%
Rationale: An estimation of the burn area can be performed by assuming
each palmar surface of the patient’s hand represents approximately 1% of
the total body surface area. (p. 273).
Chapter 16 Trauma
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 20 of 25
20. An ambulance arrives with a 13-year-old pedestrian hit by a car. Identified injuries
reported by paramedics include multiple abrasions to the head and face, a large, actively
bleeding laceration to the forehead, hip pain with the leg externally rotated, and bruising
across the chest and abdomen. The patient is in full spinal immobilization and has two
intravenous catheters and a nonrebreather oxygen mask in place. Vital signs are BP
110/70 mm Hg, HR 118 beats/minute, RR 24 breaths/minute, and SpO2 96%. The
Glasgow coma scale score is 15. What is the priority?
A. Computed tomography
Rationale: Although CT scans are an important diagnostic tool and are
indicated for this patient for the cervical spine, chest, and abdomen, this
test would not be performed until the primary and secondary surveys are
completed and any primary or secondary issues are addressed (p. 270).
B. Immobilize the femur
Rationale: A femur fracture is concerning because of the potential for
blood loss. However, the priority for this patient is controlling the obvious
bleeding. Obvious external bleeding is controlled in the primary survey
and femur immobilization is applied in the secondary survey (p. 283).
C. A pressure dressing to the forehead
Rationale: Control of active external bleeding is a high priority in
order to minimize further hemodynamic instability during the
circulation assessment in the primary survey. Younger children can
lose relatively large amounts of blood from scalp lacerations (p. 13).
D. Focused assessment with sonography for trauma (FAST)
Rationale: Sonography may be useful given this patient’s evidence of
abdominal injuries, but the active bleeding from the forehead laceration is
the priority (p. 282).
Chapter 16 Trauma
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 21 of 25
21. A 15-year-old with a history of schizophrenia is taking risperidone (Risperdal) and
lithium (Eskalith). She presents with dystonia, akinesia, a shuffling gait, muscle rigidity,
and tremors. What does the nurse suspect is the cause of these signs and symptoms?
A. Extrapyramidal symptoms
Rationale: Extrapyramidal symptoms are an adverse effect caused by
antipsychotic medications, including risperidone (Risperdal),
aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa),
lithium (Eskalith), and valproate (Depakote). Extrapyramidal
symptoms are characterized by akinesia, akathisia, dystonia,
oculogyric crisis, pseudoparkinsonism or a shuffling gait, drooling,
muscle rigidity, tremor, and rabbit syndrome (p. 324).
B. Tardive dyskinesia
Rationale: Tardive dyskinesia is as effect caused by antipsychotic
medications, including risperidone (Risperdal), aripiprazole (Abilify),
quetiapine (Seroquel), olanzapine (Zyprexa), lithium (Eskalith), and
valproate (Depakote). Tardive dyskinesia presents with tongue protrusion,
lip smacking, and involuntary movements of the mouth, fingers and
extremities (p. 324).
C. Neuroleptic malignant syndrome
Rationale: Neuroleptic malignant syndrome is a potentially fatal syndrome
caused by antipsychotic medications, including risperidone (Risperdal),
aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa),
lithium (Eskalith), and valproate (Depakote) and can be precipitated by
dehydration. Neuroleptic malignant syndrome presents with high fever,
blood pressure instability, tachycardia, agitation, diaphoresis, pallor,
muscle rigidity, and altered mental status (p. 324).
D. Serotonin syndrome
Rationale: Serotonin syndrome is the most serious adverse effect of
selective serotonin reuptake inhibitors (SSRIs). Serotonin syndrome is
characterized by altered mental status, flushing, diaphoresis, diarrhea,
nausea, vomiting, myoclonus, tremors, hyperthermia, and tachycardia (p.
323–324).
Chapter 18 Behavioral Emergencies
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 22 of 25
22. Which of the following burn injury patterns and history indicates suspected child
maltreatment?
A. A 5-cm (2 inch) linear, superficial partial-thickness burn with irregular edges on
the leg of a preschooler, reportedly from bumping into curling iron left on a low
table
Rationale: Although inflicted injury should be considered in all pediatric
burns, this is a plausible history for this burn in a child who is ambulatory.
Burns from irons are particularly suspicious if they are deep and have
sharp edges, such as would be seen with prolonged contact with the iron in
a single position. The irregular edges are more likely to be associated with
accidental injury (p. 351).
B. A deep partial-thickness, sharply demarcated burn on the buttocks of a
toddler, reportedly from the child turning on the hot water in the bath
Rationale: Forced submersion in scalding water tends to produce
burns that are deep and sharply demarcated. There may also be areas
that were spared from contact, such as skin folds, as the child was
held down. Unintentional scald burns in toddlers falling or getting
into a hot bath will have irregular edges and splash marks as they
attempt to get out of the water (p. 351).
C. A 2-cm (0.75 inch) linear partial-thickness burn on the arm of toddler, reportedly
from walking and bumping into a lighted cigarette
Rationale: A linear burn from a cigarette would be consistent with a brief,
accidental injury, as described here. This story would be concerning if the
child is too young to walk or if the burn pattern was characteristically
round and deep, reflecting the cigarette being held against the skin (p.
351).
D. A partial-thickness burn with irregular edges and splash pattern on the chest and
right hand of a 7-year-old reportedly spilling a bowl of hot noodles from the
microwave
Rationale: Scald burns from spills typically spread downward from the
falling liquid and will have surrounding splash marks (p. 351).
Chapter 20 Child Maltreatment
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 23 of 25
23. A mother presents to the emergency department with a 6-week-old infant with no
medical issues after a normal delivery, until yesterday. Mom states he has been eating
poorly, vomiting, and that “he’s hard to wake up.” The infant is responsive only to
painful stimuli. The anterior fontanel is bulging. He is mildly tachycardic, but otherwise
vital signs are normal. What diagnostic evaluation will the nurse expect for this infant?
A. Upper gastrointestinal (GI) series
Rationale: While the infant has been vomiting, this is likely from
increased intracranial pressure, as indicated by the bulging fontanel, not
from any gastrointestinal process. An upper GI series is not indicated at
this time (p. 276).
B. Skeletal survey
Rationale: The infant is exhibiting signs and symptoms of abusive
head trauma, formerly known as shaken baby syndrome. A skeletal
survey should be done in order to detect any rib fractures, which can
be a concurrent injury with abusive head trauma. Other signs and
symptoms consistent with abusive head trauma include bruising
consistent with grip marks around the chest, fixed and dilated pupils,
and retinal hemorrhages. In addition, a skeletal survey may reveal
healing fractures from previous abuse. Computed tomography of the
head should also be done to evaluate for cerebral edema or
intracranial hematoma (p. 351). C. Lumbar puncture
Rationale: With vomiting, altered mental status, and bulging fontanel
sepsis or meningitis should be considered. With a normal temperature the
symptoms are more likely to be related to trauma and the urgency for
analysis of the cerebrospinal fluid is not as high. Once abusive head
trauma has been eliminated, sepsis should be considered (p. 148–149).
D. Blood gas analysis
Rationale: With normal vital signs, a blood gas analysis would not be
indicated at this time (p. 183).
Chapter 20 Child Maltreatment
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 24 of 25
24. A malfunctioning oxygen tank explodes near a child’s bed in the emergency department,
resulting in an extensive burn injury to the child. Four nurses participate in the child’s
immediate care. Which nurse requires intervention after this critical incident?
A. One who refuses to participate in critical incident stress debriefing
Rationale: Critical incident stress debriefing may not be helpful for all
individuals and this nurse may have other ways to handle his or her own
stress. Refusing is not necessarily a sign of stress (p. 362)
B. One who readily talks about the incident and how he reacted
Rationale: Part of the process of critical incident stress debriefing is being
able to discuss what happened and the effects and responses to the incident
(p. 362).
C. One who admits experiencing burnout and asks for a week leave of absence
Rationale: Part of the process of dealing with critical incident stress is the
examination of one’s own feelings and responses. Burnout sometimes can
occur and the ability to admit it and ask for help is a positive sign (p. 362).
D. One who is not sleeping because of dreams of the incident
Rationale: This nurse is having a difficult time detaching and this
need to come in on off hours to visit may be an expression of guilt,
which is a sign of stress caused by critical incidents (p. 362).
Chapter 21 Crisis
Emergency Nursing Pediatric Course 4th Edition Practice Test Annotated Answer Key
Page 25 of 25
25. Two ambulances collide in front of the hospital. The victims include patients and family
members with three pediatric victims. Using the JumpSTART triage system, which
category assignment will the nurse give to a 2-year-old who is lying on the ground, alert
and crying with spontaneous respirations of 36 breaths/minute and present peripheral
pulses?
A. Green
Rationale: With JumpSTART, all ambulatory patients are designated
green unless unresponsive (p. 370).
B. Yellow
Rationale: The JumpSTART mass casualty triage system evaluates
the ability to ambulate, respiration, perfusion, and mental status. In
this case, the child is nonambulatory but has spontaneous respiratory
greater than 15 and less that 45 breaths per minute with palpable
peripheral pulses, so he or she is triaged to the yellow category. The
yellow category is for those patients who can be delayed or deferred
(p. 370).
C. Red
Rationale: With JumpSTART, the red category is for those patients who
require immediate intervention. They are not ambulatory and have an
abnormal respiratory rate or a normal respiratory rate and pattern with no
pulse or a present peripheral pulse but unresponsive (p. 370).
D. Black
Rationale: With JumpSTART, the black category is for those patients who
are dead or unsalvageable, which is defined as no spontaneous respirations
after airway positioning and no peripheral pulses after 5 rescue breaths (p.
370).
Chapter 22 Disaster