1 :

School-age child admitted, diagnosed with cystic fibrosis at 3 months of age, has experienced failure to thrive, and has chronic obstructive pulmonary disease. The child presents with wheezing, rhonchi, paroxysmal cough, and dyspnea. The parent reports large, frothy foul- smelling stools. The child has deficient levels of vitamin A, D, E, and K.

Barrel-shaped chest

Clubbing of the fingers bilaterally

Respiratory rate 40/min with wheezing and rhonchi noted bilaterally, dyspnea, and paroxysmal cough

A nurse is reviewing the child's medical record. Which of the following medications should the nurse expect the provider to prescribe or reconcile from the child's home medication list?Select all that apply.

Answer Options

Hint : 🫁 CF needs enzymes, mucus thinners, and fat-soluble vitamins

Correct Answers:

  • Water-soluble vitamins
  • Dornase alfa
  • Pancreatic Apase

Rationale :

A. Water-soluble vitamins (Fat-soluble vitamins A, D, E, K in water-miscible form)

🫁 Children with cystic fibrosis have exocrine pancreatic insufficiency, leading to malabsorption of fat-soluble vitamins (A, D, E, and K).

🫁 These vitamins are essential for vision (A), bone health (D), neurological function (E), and clotting (K)—all of which are at risk due to fat malabsorption.

🫁 The vitamins should be given in a water-miscible form, which allows for absorption without the need for pancreatic enzymes.

🫁 This supplementation is lifelong and essential for growth, immune function, and overall development in children with CF.

B. Dornase alfa

🫁 Dornase alfa (Pulmozyme) is a recombinant human deoxyribonuclease that breaks down DNA in thick pulmonary secretions, improving airway clearance.

🫁 It is a standard part of respiratory management in CF to reduce the viscosity of sputum and prevent recurrent infections and airway obstruction.

🫁 Administered via nebulizer, it should be given daily or twice daily, depending on severity.

🫁 Dornase alfa improves pulmonary function, reduces exacerbations, and enhances quality of life in CF patients with chronic obstructive lung disease.

D. Pancreatic lipase (Pancreatic enzyme replacement therapy – PERT)

🫁 Children with CF need pancreatic enzyme replacement therapy (PERT) because their pancreatic ducts are blocked, preventing normal secretion of digestive enzymes.

🫁 Pancreatic lipase, amylase, and protease are replaced to allow for digestion and absorption of nutrients, especially fats and proteins.

🫁 This therapy helps reduce steatorrhea (foul-smelling, frothy stools), promotes weight gain, and improves nutritional status.

🫁 Pancreatic enzymes must be taken with every meal and snack, and doses are based on body weight and stool consistency.

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2 :

• Diphenhydramine 10 mg PO 4 times per day

• Pimecrolimus 1% cream apply to skin lesions daily

Which of the following statements should the nurse plan to include in the discharge instructions for the child's guardian? Select all that apply.

Answer Options

Hint : 🧴 Moisturize, protect skin, manage flares—eczema is not contagious

Correct Answers:

  • "You should use a mild detergent for your child's laundry."
  • "You can apply gloves to your child's hands."
  • "You should cut and file your child's fingernails frequently."
  • "You should apply emollients to your child's skin after bathing '
  • "Your child will experience occasional flare-ups of this condition."

Rationale :

A. "You should use a mild detergent for your child's laundry."

🧴 Children with atopic dermatitis have hypersensitive skin, and exposure to harsh chemicals or fragrances can trigger or worsen flare-ups.

🧴 Using fragrance-free, dye-free detergents minimizes the risk of contact dermatitis or irritant reactions.

🧴 It’s also helpful to double-rinse laundry to remove residual soap.

🧴 This preventive strategy is essential for long-term skin barrier protection and reduces need for medical intervention.

B. "You can apply gloves to your child's hands."

🧴 Excessive scratching can lead to skin breakdown, bleeding, and secondary infections, particularly during sleep.

🧴 Applying soft cotton gloves or mittens can minimize trauma caused by unconscious scratching.

🧴 Gloves should be kept clean, dry, and removed periodically to inspect the skin underneath.

🧴 This is a simple and effective protective intervention, especially for toddlers who cannot fully control scratching behavior.

C. "You should cut and file your child's fingernails frequently."

🧴 Keeping fingernails short and smooth reduces damage from scratching, which worsens inflammation and increases risk of bacterial superinfection (e.g., Staph aureus).

🧴 Filing any rough or sharp edges prevents skin tearing.

🧴 Parents should be instructed to check nails at least weekly and maintain strict hand hygiene.

🧴 This is an important part of skin care and infection prevention for children with atopic dermatitis.

D. "You should apply emollients to your child's skin after bathing."

🧴 Emollients are foundational in managing atopic dermatitis, as they help restore the skin barrier and maintain hydration.

🧴 Applying them immediately after bathing (within 3 minutes) seals in moisture and reduces trans-epidermal water loss.

🧴 Daily use of thick moisturizers can reduce flare frequency and improve skin texture.

🧴 Emollients should be fragrance-free and hypoallergenic, and applied even when the skin appears clear.

G. "Your child will experience occasional flare-ups of this condition."

🧴 Atopic dermatitis is a chronic, relapsing inflammatory condition that tends to flare periodically due to triggers like allergens, stress, dry weather, or infections.

🧴 Families should be educated that remission is possible, but flare-ups are common, especially during seasonal changes or illness.

🧴 This promotes realistic expectations, reinforces ongoing skin care routines, and improves treatment adherence.

🧴 Early identification and intervention during flares helps minimize complications and discomfort.

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3 :

0930: 
Parent presents child to provider's office. Parent reports the child has had a fever for 2 days and that the child has cried more than usual Parent also reports the child has had a decreased appetite for the last 24 hr Child febrile and lethargic.

0945: 
Notified provider of parent reports and child's fever New prescriptions received.

1000:
 Urine sample obtained via sterile straight catheter.

Drag words from the choices below to fill in each blank in the following sentence. The child is at risk for developing and

Hint : 🧪 UTI → pyelonephritis → kidney damage (scarring)

Correct Answers

  • Blank 1 Correct Option: pyelonephritis
  • Blank 2 Correct Option: renal scarring
Rationale :

A. Pyelonephritis

🧠 A urinary tract infection (UTI) in a febrile infant or toddler raises strong concern for pyelonephritis, which is an upper urinary tract infection involving the renal pelvis and kidney parenchyma.

🧠 The child is presenting with fever, irritability, lethargy, and decreased appetite, all of which are non-specific signs of systemic illness often seen in young children with kidney infections.

🧠 Sterile catheterization for urine collection suggests that the provider suspects a true UTI, ruling out contamination from external flora.

🧠 In this age group, pyelonephritis often goes undiagnosed early due to subtle symptoms, making timely detection and treatment essential to prevent complications.

B. Renal scarring

🧠 Recurrent or poorly treated pyelonephritis in young children can lead to renal scarring, which refers to permanent damage to the kidney tissue.

🧠 Scarring can impair renal function over time and is one of the leading causes of chronic kidney disease in pediatric patients.

🧠 Risk of renal scarring increases in infants and toddlers because their immune systems are immature and their urinary tracts may have underlying anatomical abnormalities, like vesicoureteral reflux (VUR).

🧠 Preventing scarring requires prompt diagnosis and antibiotic treatment of the infection, along with imaging studies to assess for reflux or structural defects when UTIs are recurrent.

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4 :

A 15-year-old adolescent is admitted for a vaso-occlusive crisis. The parent reports that the adolescent has a low-grade fever and has vomited for 3 days_ The adolescent reports having right- sided and low back pain They also report hands and right knee are painful and swollen. The client reports pain as 8 on a scale of 0 to 10.

The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.

Answer Options

Hint : 🩸 Oxygen, folate, hydroxyurea, vaccine, restrict PO

Correct Answers:

  • Administer folic acid as prescribed.
  • Monitor oxygen saturation continuously
  • Restrict oral intake.
  • Instruct the parent to ensure the pneumococcal vaccine is current
  • Give oral hydroxyurea.

Rationale :

A. Administer folic acid as prescribed

🩸 Folic acid is a key component of treatment in sickle cell disease to support ongoing erythropoiesis.

🩸 Due to chronic hemolysis, individuals with SCD have a high turnover of red blood cells, which increases the body's need for folate, a vitamin essential for DNA synthesis and cell division.

🩸 Folic acid supplementation helps prevent megaloblastic anemia and supports the production of healthy RBCs, which can reduce symptoms over time.

🩸 It is a maintenance therapy, not specific to the acute episode but critical for long-term management.

B. Monitor oxygen saturation continuously

🩸 Hypoxia is a potent trigger for sickling of red blood cells, which leads to vaso-occlusion, ischemia, and pain.

🩸 Continuous monitoring of oxygen saturation enables the nurse to detect early signs of desaturation, which may not be evident through clinical observation alone.

🩸 Ensuring oxygenation above 95% is essential to prevent further sickling and organ damage.

🩸 This allows for timely oxygen therapy and prevents complications like acute chest syndrome, a life-threatening condition in SCD patients.

D. Restrict oral intake

🩸 The adolescent has been vomiting for three days, placing them at risk for fluid and electrolyte imbalances, aspiration, and dehydration.

🩸 While hydration is critical in sickle cell crises to reduce blood viscosity and improve circulation, oral intake should be restricted temporarily until vomiting subsides.

🩸 IV fluids are the safer route to restore volume and maintain hydration during acute gastrointestinal symptoms.

🩸 Once symptoms resolve, gradual oral intake can be resumed with careful monitoring.

E. Instruct the parent to ensure the pneumococcal vaccine is current

🩸 Individuals with sickle cell disease are at high risk for encapsulated bacterial infections, especially Streptococcus pneumoniae, due to functional asplenia.

🩸 The pneumococcal vaccine is a critical preventive measure to reduce the risk of life-threatening infections such as sepsis, meningitis, and pneumonia.

🩸 Routine vaccination should be verified and kept up-to-date according to CDC guidelines for children with chronic illnesses.

🩸 This is part of comprehensive education and long-term management, even during hospitalization for acute crises.

H. Give oral hydroxyurea

🩸 Hydroxyurea is a disease-modifying medication that increases fetal hemoglobin (HbF) levels, reducing the number of sickled red blood cells.

🩸 While it's primarily used for long-term prevention, it is typically continued during hospitalization to maintain its effects.

🩸 Hydroxyurea reduces the frequency of vaso-occlusive crises, the need for transfusions, and the severity of chronic pain.

🩸 Its benefits are well-documented in reducing morbidity and mortality in adolescents with moderate to severe sickle cell disease.

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5 :

0730: Child presents to the emergency department (ED). Guardians report the child woke up coughing with a low-grade fever Child appears alert and restless in guardian's arms_ Respirations easy, no cough noted.

0800: Child became agitated_ Hoarse cry noted with audible inspiratory stridor Barking, non-productive cough present.

For each of the following findings, click to specify if the finding is consistent with acute laryngotracheobronchitis or pneumonia. Each finding may support more than one disease process.

Options Acute Laryngotracheobronchitis Pneumonia
Temperature
Cough findings at 0800
Irritability
Stridor

Hint : 🌬️ Barking cough + stridor = Croup

Correct Answers

  • Temperature [ Acute Laryngotracheobronchitis ; Pneumonia ]
  • Cough findings at 0800 [ Acute Laryngotracheobronchitis ]
  • Irritability [ Acute Laryngotracheobronchitis ; Pneumonia ]
  • Stridor [ Acute Laryngotracheobronchitis ]
Rationale :

A. Temperature

🌬️ Consistent with Acute Laryngotracheobronchitis (Croup):

🌬️ Children with acute laryngotracheobronchitis (LTB) often present with a low-grade fever, typically between 37.5°C to 39°C (99.5°F to 102.2°F).

🌬️ The fever arises from a viral infection, most commonly parainfluenza virus, which affects the upper airway including the larynx, trachea, and bronchi.

🌬️ Fever may be one of the first signs prompting concern in caregivers, but in croup, it is usually mild and not the primary symptom.

🌬️ The initial report of low-grade fever is typical of early croup presentation, especially when paired with stridor and barking cough.

🌬️ Consistent with Pneumonia:

🌬️ Fever is also a classic sign of pneumonia, which may range from low-grade to high-grade depending on the etiology (e.g., viral vs. bacterial).

🌬️ In viral pneumonia, the fever can remain low-grade, while in bacterial pneumonia, it may exceed 39°C (102.2°F).

🌬️ Therefore, a low-grade fever can be present in both conditions and is not diagnostic on its own, but must be evaluated in context with respiratory signs.

B. Cough findings at 0800 (Barking, non-productive cough)

🌬️ Consistent with Acute Laryngotracheobronchitis (Croup):

🌬️ A barking, seal-like cough is the hallmark symptom of croup and occurs due to inflammation and edema in the subglottic space.

🌬️ It is typically non-productive, harsh, and worsens at night or when the child is crying, agitated, or exposed to cold air.

🌬️ This cough is one of the most recognizable features that differentiates croup from lower respiratory illnesses.

🌬️ The child in this case developed this cough after an initial phase of restlessness and mild fever, strongly aligning with classic croup progression.

🌬️ Not consistent with Pneumonia:

🌬️ Cough associated with pneumonia is usually productive (especially in older children), may have wet or coarse sounds, and is typically not described as "barking."

🌬️ In younger children, the cough may be non-specific, but it still tends to reflect lower airway congestion, not the distinctive seal-like tone of croup.

🌬️ A barking cough is not seen in pneumonia and thus is highly specific to upper airway involvement, particularly croup.

C. Irritability

🌬️ Consistent with Acute Laryngotracheobronchitis (Croup):

🌬️ In croup, irritability is often seen when the child is experiencing airway obstruction, discomfort, or is unable to effectively breathe or rest.

🌬️ Increased restlessness may occur as respiratory effort increases, particularly when stridor or labored breathing develops.

🌬️ The inflammation of the airway and associated respiratory distress contribute to anxiety and crying, further worsening the symptoms.

🌬️ Consistent with Pneumonia:

🌬️ Children with pneumonia may also become irritable, especially if they are febrile, fatigued, or experiencing hypoxia or pain from coughing or pleuritic involvement.

🌬️ Irritability is a non-specific symptom common to many pediatric illnesses, particularly when systemic infection or respiratory distress is present.

🌬️ In this case, the child’s irritability could apply to either diagnosis, and must be interpreted alongside other more specific symptoms.

D. Stridor

🌬️ Consistent with Acute Laryngotracheobronchitis (Croup):

🌬️ Inspiratory stridor is a key distinguishing sign of croup, caused by subglottic narrowing due to inflammation of the larynx and trachea.

🌬️ It is typically audible without a stethoscope, and becomes more prominent with agitation, crying, or exertion.

🌬️ Stridor is a direct reflection of upper airway obstruction, and its presence strongly supports croup over any lower respiratory infection.

🌬️ In this case, the development of hoarseness and audible stridor after initial symptoms confirms upper airway involvement, characteristic of croup.

🌬️ Not consistent with Pneumonia:

🌬️ Pneumonia primarily affects the lower respiratory tract (alveoli, bronchioles), and does not cause stridor.

🌬️ Instead, pneumonia produces crackles, wheezing, or diminished breath sounds, depending on the extent and location of the infection.

🌬️ Stridor is not a feature of pneumonia and should direct diagnostic consideration toward upper airway conditions such as croup, foreign body aspiration, or epiglottitis.

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6 :

Hint : 🍭 Cold treat encourages intake

Correct Answers:

  • Provide an ice pop after administering the medication.

Rationale :

🔹 Preschool-age children often resist oral medications due to taste or unfamiliar textures.

🔹 Positive reinforcement, such as offering an ice pop, can make the experience more tolerable and appealing.

🔹 The cold sensation may also help numb taste buds, reducing lingering unpleasant flavors.

🔹 This approach maintains the medication's integrity while supporting medication adherence.

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7 :

Hint : 🪑 Comfort helps stillness

Correct Answers:

  • "Your child can rest on your lap during the procedure."

Rationale :
🪑 Resting in a parent’s lap provides comfort and helps reduce anxiety during an electrocardiogram (ECG). 🪑 The ECG is a painless and quick test that requires the child to remain still for a few seconds to record accurate heart activity. 🪑 This position improves cooperation and minimizes movement artifacts in the ECG tracing. 🪑 It's a developmentally appropriate strategy for toddlers and preschoolers in clinical settings.
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8 :

Hint : 💩 Fatty stool signals celiac

Correct Answers:

  • Steatorrhea

Rationale :
💩 Children with celiac disease develop steatorrhea due to fat malabsorption resulting from damage to the intestinal villi. 💩 Steatorrhea is characterized by pale, foul-smelling, bulky stools that float due to high fat content. 💩 Other findings include abdominal distension, irritability, growth delay, and deficiency in fat-soluble vitamins (A, D, E, K). 💩 A strict gluten-free diet is essential to manage this autoimmune condition and prevent complications.
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9 :

Hint : 🤕 Monitor for spinal headache

Correct Answers:

  • Headache

Rationale :
🤕 A headache is a common complication following a lumbar puncture due to cerebrospinal fluid (CSF) leakage at the puncture site. 🤕 The headache is usually postural—worsening when sitting up and improving when lying down. 🤕 It results from a drop in intracranial pressure, which stretches pain-sensitive structures. 🤕 Monitoring and encouraging fluid intake or a blood patch if severe may be indicated.
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10 :

Hint : 🩸 External filter cleans blood

Correct Answers:

  • "Hemodialysis uses an artificial membrane outside the body to clean your child's blood "

Rationale :
🩸 Hemodialysis involves circulating blood through a machine with an artificial semipermeable membrane (dialyzer) to remove waste, excess fluids, and toxins. 🩸 This extracorporeal process mimics kidney function in children with chronic renal failure. 🩸 It requires vascular access and is typically done 2–3 times per week in a dialysis center. 🩸 This is different from peritoneal dialysis, which uses the abdominal cavity.
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