Question

A nurse is caring for an infant in the emergency department.

Answer 1

Correct Answers:

Stabilize the infant's spine.
Palpate fontanel level.
Assess pupillary reaction to light.
Measure the infant's head circumference.
Evaluate for the presence of a Babinski reflex

Rationale :

🔸 A. Stabilize the infant's spine:

✔️ In any trauma involving a fall—especially in infants—cervical spine injury must be ruled out.

✔️ Immobilization is critical until spinal cord injury is excluded to prevent neurological compromise.

✔️ This is especially important given the mechanism of injury (fall down stairs) and signs of altered consciousness.

🔸 B. Palpate fontanel level:

✔️ The anterior fontanel in infants offers a noninvasive means of assessing intracranial pressure (ICP).

✔️ A bulging or tense fontanel may indicate increased ICP, while a sunken fontanel suggests dehydration.

✔️ Monitoring this helps detect neurological deterioration in cases like subdural hematoma.

🔸 C. Assess pupillary reaction to light:

✔️ Pupillary response provides essential information on brainstem function and intracranial pressure.

✔️ Changes in pupil size, symmetry, or reactivity may signal brain herniation or deterioration.

✔️ This is a priority neuro check in any infant with head trauma.

🔸 E. Measure the infant's head circumference:

✔️ In infants, head circumference helps identify swelling, hydrocephalus, or hematoma expansion.

✔️ Monitoring trends in head size can be critical for detecting gradual increases in ICP.

✔️ This is especially important with subdural bleeds, where pressure can build over time.

🔸 F. Evaluate for the presence of a Babinski reflex:

✔️ The Babinski reflex is a neurologic assessment that helps evaluate cortical and spinal cord function.

✔️ An absent or asymmetric reflex may signal central nervous system damage.

✔️ In infants, the Babinski should be positive (toes fan out) until ~1 year—any deviation from normal should be assessed.

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Answer 2

Correct Answers

Blank 1 Correct Option: Stevens-Johnson syndrome
Blank 2 Correct Option: Skin rash

Rationale :

🔹 A. Stevens-Johnson syndrome:

✔️ Phenytoin is an antiepileptic drug known to cause rare but serious adverse effects, including Stevens-Johnson syndrome (SJS), a life-threatening hypersensitivity reaction.

✔️ The presence of itchy, dry, hyperpigmented patches with scratch marks and dried blood on the arms suggests an evolving cutaneous reaction—a potential early sign of SJS.

✔️ SJS often starts with nonspecific flu-like symptoms followed by a painful rash or mucocutaneous lesions and epidermal detachment, so early skin signs warrant concern.

✔️ The phenytoin level is subtherapeutic (6 mcg/mL; normal range 10–20 mcg/mL), meaning it's ineffective and the child is still at risk for toxic adverse effects like SJS, especially in the early months after starting the drug.

🔹 B. Skin rash:

✔️ The skin rash is a hallmark early indicator of SJS, particularly in children recently started on high-risk medications like phenytoin.

✔️ While the cough and wheeze point to asthma, the rash is more specific to phenytoin's adverse effects.

✔️ Stevens-Johnson syndrome may also present with mucosal involvement or systemic symptoms, so a progressing rash must be evaluated urgently.

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Answer 3

Correct Answers:

The child prefers being with their friends rather than family

Rationale :

🔹 Preferring peers over family is a normal developmental behavior in adolescents and is not in itself a sign of depression.

🔹 The other choices—weight changes, excessive sleep, and poor academic performance—are established clinical indicators of depressive disorders in adolescents.

🔹 Depression often presents as changes in appetite, sleep patterns, energy, concentration, and social withdrawal.

🔹 The statement reflects a misunderstanding of age-appropriate behavior rather than depressive symptoms.

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Answer 4

Correct Answers:

Foster self-care activities.

Rationale :

🔸 Children with hemiplegic cerebral palsy benefit from maximizing independence and motor function.

🔸 Fostering self-care promotes developmental progression, enhances self-esteem, and supports long-term coping.

🔸 While modifying the environment is helpful, promoting autonomy is the priority in care planning.

🔸 Communication and respite are also important, but self-care directly addresses the child’s functional capability.

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Answer 5

Correct Answers:

"I only need to catheterize myself twice every day."

Rationale :

◽ Clients with spina bifida often have neurogenic bladder, requiring intermittent catheterization every 3–4 hours, not just twice daily.

◽ Infrequent catheterization can lead to urinary retention, infections, and renal damage.

◽ The other statements reflect positive and accurate self-care behaviors, including mobility, hydration, and bowel regimen.

◽ Teaching should reinforce correct catheterization frequency and technique.

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Answer 6

Correct Answers:

"If child is not able to eat solid foods, you can offer fluids with some carbohydrates"
"Encourage fluid without sugar during illness"
Test the blood/urine for ketones."

Rationale :

✴️ A. Encourage sugar-containing fluids during hypoglycemia:

✔️ Children with diabetes are at risk for hypoglycemia during illness because they may have decreased appetite but continue using insulin.

✔️ If the child is unable to eat solid food, offering sugar-containing fluids like fruit juice or regular (non-diet) soda helps prevent dangerously low blood glucose levels.

✔️ The ADA recommends maintaining 15 g of simple carbs every few hours when solid intake is reduced during sick days.

✔️ This also helps prevent hypoglycemia-induced seizures or loss of consciousness in pediatric clients.

✴️ C. Encourage intake of sugar-free fluids:

✔️ Sugar-free fluids such as water, broth, or electrolyte solutions prevent dehydration, which is a common concern during illness, especially if fever or vomiting is present.

✔️ Keeping hydrated also supports kidney function and helps flush out excess ketones in the urine.

✔️ It’s important to balance hydration with the need to avoid excessive blood sugar fluctuations.

✔️ This is part of general sick-day management in children with type 1 diabetes.

✴️ E. Test the urine for ketones:

✔️ Ketone testing is critical when a diabetic child is ill, has a fever, or has blood glucose >240 mg/dL, as this may indicate the onset of diabetic ketoacidosis (DKA).

✔️ Ketones in the urine suggest the body is breaking down fat for energy due to insufficient insulin or inadequate glucose availability.

✔️ Early identification of ketonuria allows for prompt intervention and helps prevent progression to life-threatening DKA.

✔️ This is a routine part of pediatric sick-day protocols in diabetes management.

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Answer 7

Correct Answers:

Perform a neurovascular assessment.

Rationale :

🟠 The priority after cast application is checking for circulation, motor, and sensory status—to prevent complications like compartment syndrome.

🟠 Early signs of neurovascular compromise include pain, pallor, paresthesia, pulselessness, and paralysis.

🟠 Ice and discharge teaching are appropriate, but not priority.

🟠 Reassurance is helpful, but does not address life or limb-threatening concerns.

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Answer 8

Correct Answers:

SLE is an autoimmune disorder that I will always have, with times of flare-ups and times of minimal to no symptoms.

Rationale :

⚫ Systemic lupus erythematosus (SLE) is a chronic autoimmune condition, with remissions and exacerbations.

⚫ It can affect multiple organs—skin, joints, kidneys, CNS, etc.—not just skin.

⚫ There is no cure, but management can minimize flares and reduce damage.

⚫ The other choices either underestimate or misrepresent the nature of the disease.

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Answer 9

Correct Answers:

Place the child in isolation.

Rationale :

💠 Bacterial meningitis is highly contagious, especially in children.

💠 Droplet isolation must be implemented immediately to prevent spread to others.

💠 Antibiotics and diagnostics (lumbar puncture, cultures) are also important, but infection control is first.

💠 This action protects both the patient and healthcare staff.

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Answer 10

Correct Answers:

Airway obstruction

Rationale :

🔺 Burns on the head, neck, and chest pose a serious risk of airway compromise due to edema.

🔺 Airway swelling can occur hours after the injury, especially in thermal burns.

🔺 While fluid loss, ileus, and infection are risks, airway is always the first priority.

🔺 Monitoring for hoarseness, stridor, or drooling is essential in such cases.

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QLexNursing

1 :
A nurse is caring for an infant in the emergency department.

Answer Options

2 :
A nurse was caring for a patient.

Correct Answers

3 :
The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 :
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 :
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 :
An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 :
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 :
A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

QLexNursing

1 : A nurse is caring for an infant in the emergency department.

Answer Options

2 : A nurse was caring for a patient.

Correct Answers

3 : The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 : A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 : A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 : A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 : A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 : An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 : A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 : A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

1 :
A nurse is caring for an infant in the emergency department.

2 :
A nurse was caring for a patient.

3 :
The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?

4 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

5 :
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

6 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)

7 :
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

8 :
An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

9 :
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

10 :
A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?