Question

A nurse is caring for an adolescent who presents to the emergency department

Answer 1

Correct Answers

lung sound [ improved ]
Dyspnea [ improved ]
Blood pressure [ improved ]
Respiratory rate [ improved ]
Heart rate [ improved ]
Oral intake [ improved ]
Oxygen saturation [ improved ]

Rationale :

🟦 1. Lung sounds — Improved

🟦 At 1500, the adolescent had dry cough and wheezing in the upper lobes, indicating airway obstruction likely due to fluid retention from heart failure.

🟦 By 1930, documentation shows only mild wheezing, demonstrating a less severe respiratory obstruction.

🟦 This improvement aligns with the expected response to furosemide, which removes excess fluid and reduces pulmonary congestion.

🟦 While not fully resolved, the decrease in wheezing indicates better ventilation and improved cardiopulmonary status.

🟩 2. Dyspnea — Improved

🟩 At 1500, dyspnea was present even while sitting upright, indicating significant respiratory distress and poor cardiac output.

🟩 By 1930, the adolescent reports dyspnea only with activity, meaning resting breathing has improved.

🟩 This pattern matches expected improvement after oxygen therapy and diuretic administration.

🟩 Activity-related dyspnea is typical in heart failure, but improvement at rest shows better oxygenation and reduced pulmonary congestion.

🟧 3. Blood Pressure — Improved

🟧 Initial BP was 143/92, showing elevated afterload commonly seen in heart failure exacerbation.

🟧 By 1930, BP decreased to 129/72, reflecting better cardiac workload and afterload reduction.

🟧 This improvement is consistent with the action of enalapril, an ACE inhibitor that reduces vascular resistance.

🟧 Improved BP supports enhanced cardiac efficiency and stabilization.

🟨 4. Respiratory Rate — Improved

🟨 The initial respiratory rate of 26/min indicated compensatory tachypnea due to poor oxygenation and fluid overload.

🟨 At reassessment, RR decreased to 20/min, which falls within the normal range for adolescents.

🟨 This demonstrates reduced respiratory effort and improved gas exchange after diuresis and oxygen therapy.

🟨 A normalized respiratory rate signals improved cardiopulmonary function.

🟪 5. Heart Rate — Improved

🟪 The apical pulse was 110/min, showing tachycardia—often a compensation for low cardiac output in heart failure.

🟪 By 1930, the heart rate dropped to 92/min, indicating reduced cardiac stress and improved ventricular function.

🟪 Digoxin improves contractility, allowing the heart to work more efficiently with fewer beats.

🟪 Lower HR reflects stabilization and better hemodynamic status.

🟫 6. Oral Intake — Improved

🟫 At 1500, the adolescent had not eaten for 3 days, indicating poor perfusion, fatigue, and possibly dyspnea that interfered with eating.

🟫 By 1930, the adolescent ate a portion of their dinner tray, showing improved energy level and respiratory comfort.

🟫 Adequate oral intake is a crucial indicator of improving systemic and metabolic stability.

🟫 This reflects better overall functioning and symptom relief.

🟩 7. Oxygen Saturation — Improved

🟩 Initial oxygen saturation was 94% on room air, which is borderline low for adolescents.

🟩 By 1930, saturation increased to 97% on 2 L/min oxygen, demonstrating more effective gas exchange.

🟩 The improved saturation is consistent with reduced pulmonary edema after diuretic therapy.

🟩 This result indicates improved clinical stability and better oxygen delivery to tissues.

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Answer 2

Correct Answers:

Alcohol use

Rationale :

🟦 The described features—low nasal bridge, smooth/long philtrum, flattened midface, thin upper lip—are classic for Fetal Alcohol Syndrome (FAS).

🟦 Alcohol disrupts facial and neurological development during early pregnancy, leading to structural abnormalities.

🟦 These facial findings are strongly associated with prenatal alcohol exposure more than any other substance.

🟦 FAS is the leading preventable cause of intellectual disability, making recognition important.

❌ Incorrect Answers

Sharing needles for drugs

❌ Leads to infections like HIV or hepatitis, not characteristic facial deformities.

Poor nutrition

❌ May cause low birth weight or growth delays, not the distinct FAS facial pattern.

Cigarette smoking

❌ Causes low birth weight and placental issues but does not produce these facial features.

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Answer 3

Correct Answers:

Explaining about the radioactive iodine procedure

Rationale :

🟩 Radioactive iodine is a standard treatment for pediatric hyperthyroidism, especially Graves disease.

🟩 Teaching the child and parents about the procedure reduces fear and builds cooperation.

🟩 RAI helps reduce thyroid hormone production by destroying hyperactive thyroid cells.

🟩 The other options belong to totally different endocrine conditions.

❌ Incorrect Answers

Describing surgery for anterior pituitary tumor

❌ Associated with Cushing disease or growth hormone issues, not hyperthyroidism.

Teaching GH injections

❌ GH treats growth hormone deficiency, unrelated to hyperthyroidism.

Showing how to give desmopressin intranasally

❌ Desmopressin treats diabetes insipidus, not thyroid disorders.

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Answer 4

Correct Answers:

Wrap the arm of the child's doll or toy prior to the procedure.

Rationale :

🟧 Preschoolers learn and cope best through demonstration and play.

🟧 Using the doll reduces fear and increases compliance by showing what will happen.

🟧 This method aligns with developmental principles for ages 3–5.

🟧 It promotes trust and reduces anxiety before the procedure.

❌ Incorrect Answers

Firm grasp support

❌ May frighten or hurt the child; gentle support is required.

Heated fan for drying

❌ Heat damages casts and causes burns.

“This will make your arm feel better.”

❌ False reassurance; not therapeutic communication.

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Answer 5

Correct Answers:

Increased serum ferritin levels

Rationale :

🟦 Ferritin measures the body's iron stores and is the earliest and most accurate indicator of recovery from iron deficiency anemia.

🟦 When diet improves and iron intake increases, ferritin levels rise before hemoglobin or hematocrit improve.

🟦 Monitoring ferritin allows clinicians to track the replenishment of iron reserves at the tissue level.

🟦 This makes ferritin the best lab result to assess successful management of iron deficiency.

❌ Incorrect Answers

Decreased platelet count

❌ Unrelated to iron status; indicates clotting abnormalities, not anemia improvement.

Improved kidney function tests

❌ Reflect renal status, not iron stores.

Elevated WBC count

❌ Indicates infection or inflammation, not anemia recovery.

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Answer 6

Correct Answers:

Initiate cardiac compressions.

Rationale :

🟩 A pulseless child with a rhythm of 32 bpm is in cardiac arrest, requiring immediate CPR.

🟩 Compressions restore blood flow to vital organs while definitive treatment is prepared.

🟩 PALS guidelines always prioritize high-quality compressions when no pulse is present.

🟩 Defibrillation and medications may follow depending on the rhythm, but compressions always come first.

❌ Incorrect Answers

Give three doses of epinephrine

❌ Epinephrine is given after CPR has begun—not the first action.

Defibrillate then CPR

❌ Defibrillation is only for shockable rhythms (VF/VT), not bradycardic arrest.

Two consecutive shocks

❌ Delays compressions and is not part of pediatric resuscitation guidelines.

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Answer 7

Correct Answers:

"Contact with molds, dust mites, and cat dander."

Rationale :

🟧 Atopic dermatitis is strongly associated with environmental allergens, including dust mites, molds, and pet dander.

🟧 These allergens activate immune inflammation, leading to itching and flare-ups.

🟧 Teaching caregivers to avoid these triggers reduces symptom frequency.

🟧 This is consistent with the chronic, allergic nature of atopic dermatitis.

❌ Incorrect Answers

Grassy areas

❌ Not a common eczema trigger.

Cold water

❌ Cold water soothes itching, not triggers it.

Unscented lotions

❌ Recommended because they reduce irritation.

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Answer 8

Correct Answers:

Behavioral problems and learning disabilities

Rationale :

🟪 Lead causes neurotoxicity, especially in the developing nervous system of children.

🟪 This leads to long-term behavioral issues, attention problems, and decreased IQ.

🟪 These effects are well-established and often permanent without early intervention.

🟪 Cognitive and behavioral impairment is the hallmark of childhood lead exposure.

❌ Incorrect Answers

Lung disease

❌ Not associated with lead exposure.

Cancer

❌ Lead is not a known pediatric carcinogen.

Asthma

❌ Asthma is allergic/inflammatory, unrelated to lead.

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Answer 9

Correct Answers:

Change to cloth diapers until the skin is healed.

Rationale :

🟫 Cloth diapers reduce exposure to chemicals and fragrances in disposable diapers.

🟫 They allow better airflow, helping the skin dry and heal faster.

🟫 Frequent changes with cloth diapers minimize moisture retention, a major cause of dermatitis.

🟫 Cloth diapers are recommended when irritation or rash is present.

❌ Incorrect Answers

Talcum powder

❌ Increases respiratory risk and is no longer recommended.

Moisturizer to wipe urine

❌ Adds moisture, which worsens irritation.

Expose to hot air

❌ Risk of burns and further skin damage.

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Answer 10

Correct Answers:

Determine if the client experiences photosensitivity.

Rationale :

🟩 A butterfly rash is strongly associated with photosensitivity, a classic SLE symptom.

🟩 Assessing photosensitivity helps identify triggers that worsen flares.

🟩 This guides teaching on sun protection and preventive care.

🟩 Assessment always comes before treatment or notification in a non-emergent situation.

❌ Incorrect Answers

Document the finding

❌ Appropriate, but not the priority action.

Apply hydrocortisone cream

❌ Requires a provider order; not a first response.

Notify provider

❌ No urgent complication; assessment is needed first.

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Assessment Finding	improved	No change
lung sound
Dyspnea
Blood pressure
Respiratory rate
Heart rate
Oral intake
Oxygen saturation

Custom NURS2221 unit VI Exam 2025

No.

1 :
A nurse is caring for an adolescent who presents to the emergency department

Correct Answers

2 :
The nurse is assessing a newborn and notes a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. What does the nurse suspect to find in the mother's history?

3 :
The nurse is preparing a teaching plan for a 10-year old child with hyperthyroidism. What information will the nurse include in the plan?

4 :
A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take?

5 :
A 5-year-old child with iron deficiency anemia is being monitored for improvement after dietary changes. Which laboratory result would best indicate successful management of the condition?

6 :
"A 6-year-old girl being treated for shock becomes pulseless. The monitor displays an irregular rhythm at 32 bpm. Which intervention is a priority?

7 :
A nurse is teaching the caregivers of a 3-year-old client who has atopic dermatitis about environmental triggers. Which of the following statements should the nurse make?

8 :
Lead poisoning in pediatric patients can result in which of the following health conditions?

9 :
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

10 :
A client is being admitted to the medical unit for exacerbation of symptoms of systemic lupus erythematosus (SLE). When assessing the client, the nurse notices a butterfly-shaped rash across the client's cheeks and bridge of the nose. Which action by the nurse is most appropriate?

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Custom NURS2221 unit VI Exam 2025

No.

1 : A nurse is caring for an adolescent who presents to the emergency department

Correct Answers

2 : The nurse is assessing a newborn and notes a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. What does the nurse suspect to find in the mother's history?

3 : The nurse is preparing a teaching plan for a 10-year old child with hyperthyroidism. What information will the nurse include in the plan?

4 : A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take?

5 : A 5-year-old child with iron deficiency anemia is being monitored for improvement after dietary changes. Which laboratory result would best indicate successful management of the condition?

6 : "A 6-year-old girl being treated for shock becomes pulseless. The monitor displays an irregular rhythm at 32 bpm. Which intervention is a priority?

7 : A nurse is teaching the caregivers of a 3-year-old client who has atopic dermatitis about environmental triggers. Which of the following statements should the nurse make?

8 : Lead poisoning in pediatric patients can result in which of the following health conditions?

9 : A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

10 : A client is being admitted to the medical unit for exacerbation of symptoms of systemic lupus erythematosus (SLE). When assessing the client, the nurse notices a butterfly-shaped rash across the client's cheeks and bridge of the nose. Which action by the nurse is most appropriate?

1 :
A nurse is caring for an adolescent who presents to the emergency department

2 :
The nurse is assessing a newborn and notes a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. What does the nurse suspect to find in the mother's history?

3 :
The nurse is preparing a teaching plan for a 10-year old child with hyperthyroidism. What information will the nurse include in the plan?

4 :
A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take?

5 :
A 5-year-old child with iron deficiency anemia is being monitored for improvement after dietary changes. Which laboratory result would best indicate successful management of the condition?

6 :
"A 6-year-old girl being treated for shock becomes pulseless. The monitor displays an irregular rhythm at 32 bpm. Which intervention is a priority?

7 :
A nurse is teaching the caregivers of a 3-year-old client who has atopic dermatitis about environmental triggers. Which of the following statements should the nurse make?

8 :
Lead poisoning in pediatric patients can result in which of the following health conditions?

9 :
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

10 :
A client is being admitted to the medical unit for exacerbation of symptoms of systemic lupus erythematosus (SLE). When assessing the client, the nurse notices a butterfly-shaped rash across the client's cheeks and bridge of the nose. Which action by the nurse is most appropriate?