4th Edition Practice Test Annotated Answer Key

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


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


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


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


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


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


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


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



remainder of the primary assessment interventions including ventilation is

performed after cervical spinal immobilization (p. 64).

D. Insert an oral airway



remainder of the primary assessment interventions including inserting an

airway, if needed, is performed after cervical spinal immobilization (p.

64).

Chapter 5 Initial Assessment


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


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


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


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


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


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



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



therapy (p. 138, 140).

Chapter 10 Respiratory Emergencies


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





D. Every 30 minutes





Chapter 11 Childhood Illness


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


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


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


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


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


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


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


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


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%




D. 5%




Chapter 16 Trauma


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


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


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


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


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


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

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